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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/operativesurgeryOOkoch 


!'f;  IV' 

i  1 1 


OPERATIVE 


SURGERY 


BY 


TH.   KOCHER,  M.D. 

PROFESSOR   AT  THE   UNIVERSITY   AND   DIRECTOR  OF  THE  SURGICAL  CLINIC 
AT   THE  BERNE  UNIVERSITY 


WITH  ONE  HUNDRED  AND  SIXTY-THREE  ILLUSTRATIONS 


NEW   YORK 

WILLIAM    WOOD   &   COMPANY 

1894 


Copyrighted,  1894, 
By  WILLIAM   WOOD   &    COMPANY 


ELECTROTYPED  AND   PRINTED   BY 

THE   publishers'    PRINTING    COMPANY 

132-136   WEST    14TH   STREET 

NEW   YORK 


COI^TE]^TS 


PART  I. 
General  Observations, 

A.  Introduction,       ............ 

B.  Anaesthesia,  ............ 

Ether  spray. — Cocaine  injection. — Ether. — Chloroform. — Bro- 
mide of  ethyl. — Chloride  of  methylene. 

C.  The  Treatment  of  Wounds, 

Atmospheric  infection. — Contact  infection. — Infection  by  im- 
plantation.—  Carbolic  acid  and  corrosive  sublimate.  —  Heat 
(steam  and  boiling). — Disinfection  of  the  hands. — Asepsis  and 
antisepsis. — The  suture  and  open  treatment  of  the  wound. — 
Drainage  and  secondary  suture. — Healing  under  the  blood 
crust. — Continuous  antisepsis. — Subnitrate  of  bismuth  and  iodo- 
form. 

D.  The  Selection  of  the  Direction  of  the  Incision, 

Drainage  openings. — Normal  incisions. 


PAGE- 
1 
4 


11 


2.S 


^ 


PART  II. 

Special  Operations. — Incisions 

The  Skull, 

a.  Soft  Parts,        .... 

1.  Temporal  artery  and  vein, 
Auriculotemporal  nerve, 
3.  Supra-orbital  artery, 
Supra-orbital  nerve, 

3.  Frontal  nerve, 

4.  Ethmoidal  nerve,  . 

5.  Occipital  artery,     . 

6.  Major  and  minor  occipital  nerves, 
h.  The  Relations  of  the  Cerebral  Convolutions  to  the 

7.  Centres  of  the  brain  cortex,  . 
Puncture  of  the  ventricles,    . 

8.  Relations  to  the  surface  of  the  skull, 
c.  Trephining,       ...... 

9.  Longitudinal  sinus, 

10.  Transverse  sinus,   .         .         .         . 

11.  Middle  meningeal  artery, 

12.  Frontal  sinus,         .... 

13.  Antrum  and  mastoid  cells,    . 

14.  Cerebellum 


Skull 


3a 

33 
33 
34 
34 
35 
3& 
36 
37 
40 
40 
47 
48 
50 
51 
52 
52 
53 
56 
57 
60 


nu9 


IV 


CONTENTS. 


F.  The  Face, 

Normal  incisions, 

15.  External  maxillary  artery, 

16.  Operations  on  the  nose, 

17.  Nose  and  nasal  cavities, 

18.  Sphenoid  cavities, 
Naso-lachrymal  canal,  . 
Frontal  sinus, 

19.  Antrum  of  Highmore,  . 

20.  Operations  on  the  nerves, 
31.  Facial  nerve. 

Trigeminus  II. ,      . 

22.  Infra-orbital  nerve, 

23.  Orbital  nerve, 

24.  Supra- maxillary  nerve, 
Trigeminus  III.,     . 

25.  Mental  nerve, 

26.  Inferior  alveolar  nerve, 

27.  Lingual  nerve, 

28.  Auriculo-temporal  nerve, 

29.  Buccinator  nerve,  . 

30.  Infra- maxillary  nerve,  . 

31 .  Resection  of  the  upper  maxilla, 

32.  Osteoplastic  resection,   . 

33.  Resection  of  the  lower  maxilla, 

34.  Osteoplastic  resection,   . 

35.  Transverse  division  of  the  cheek, 

36.  Incisions  in  the  tongue  and  the  floor  of  the 

G.  The  Upper  Lateral  Cervical  Triangle, 
The  Normal  Incision  for  the  Upper  Cervical  Triangle, 

37.  External  carotid  artery, 

38.  Superior  thyroid  artery, 

39.  Lingual  artery,      .         .        -.         . 

40.  Internal  carotid  artery, 

41.  Hypoglossal  nerve, 

42.  Lingual  nerve,       .... 

43.  Superior  laryngeal  nerve, 

44.  Internal  and  common  jugular  vein, 

45.  Accessory  nerve,    .         .         ... 

46.  Lateral  pharyngotomy. 
With  resection  of  the  upper  maxilla, 
"With  excision  of  the  lower  maxilla. 
Inferior  pharyngotomj^ 

47.  Median  pharyngotomy, 
H.    The  Anterior  Cervical  Triangle, 

48.  Common  carotid  artery, 

49.  Common  jugular  vein,  . 

50.  Vagus  nerve,  . 

51.  Inferior  thyroid  artery, 
Inferior  laryngeal  nerve. 


mouth. 


CONTENTS. 


%■ 


Triangle 


illary,    subscapular 


52.  Vertebral  artery,    . 

53.  OEsophagotomy, 

54.  Retro  (Tesopliageal  space 

55.  Tracheotomy, 
Crico- tracheotomy, 
Inferior  tracheotomy, 

56.  Laryngotomy, 

57.  Laryngectomy, 

58.  Innominate  artery, 

59.  Excision  of  the  diseased  thyroid  gland 
J.     The  Lower  Lateral  Cervical  Triangle, 

The  Normal  Incision  for  the  Lower  Lateral  Cervica 

60.  Subclavian  artery, 

61.  Accessory  nerve  (external  branch), 
63.  Subcutaneus  colli  nerve, 

63.  Large  auricular  nerve,  ... 

64.  Dorsalis   scapulae,     suprascapular,    ax 

anterior  and  posterior  thoracic  nerves, 
K.    The  Nuchal  Region,    .... 
L.     The  Thorax 

65.  Internal  mammary  artery 

66.  Intercostal  artery, 

67.  Intercostal  nerve,  . 

68.  Thoracotomy, 

69.  Resection  of  the  ribs,     . 

70.  Resection  of  larger  portions  of  the  chest  wall 

71.  Opei'ations  on  the  lungs, 
M.    The  Spinal  Column, 

72.  Opening  the  spinal  canal, 
N.    Lumbar  Region, 

Normal  incision,    .... 

73.  Nephrotomy  and  nephrectomy, 

74.  Ureter, 

75.  Splenotomy,  ..... 
O.    Abdomen, 

Normal  incisions,  .... 
Hypochondrium,    .... 

76.  Cholecystotomy  and  cholecystectomy, 
Hypogastrium,       .... 
Common  and  external  iliac  arteries, 
Opening  the  inguinal  canal, 

77.  Castration.     Excision  of  the  tunica  vaginalis, 

78.  Inguinal  herniotomy,     . 

79.  Isolation  of  the  round  ligament,    . 

80.  Resection  of  the  vermiform  apjDeudix 

81.  Formation  of  a  fecal  fistula, 

82.  Formation  of  an  artificial  anus.    . 

83.  Resection  and  sutui'e  of  the  intestine, 

84.  High  supra-pubic  cystotomj-, 

85.  Opening  of  the  bladder  with  resection  of  the  symphysis 


PAGE 

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129 
130 
131 
132 
134 


VI 


CONTENTS. 


P.    Perineum, 

86.  Perineal  lithotomy, 

87.  Opening   of   the  cavernous  and  bulbous   portion   of  the 

urethra, 

88.  Opening  of  the  membranous  and  prostatic  portion  of  the 

urethra, 
Exposure    of    the  prostate,   seminal    vesicles,    and 
deferentia,         ..... 

89.  Internal  pudendal  artery,    .         . 
Internal  pudendal  nerve, 

'Q.    Sacral  Region, 

90.  Resection  and  excision  of  the  rectum, 
R.    Upper  Extremity, 

a.  Shoulder  Region 

91.  Subclavian  artery,        .... 

92 .  Superior  thoracic  artery, 

93.  Thoracico-acromial  artery, 

94.  Long  thoracic  artery,  .... 

b.  Axilla, 

95.  Axillary  artery, 

96.  Anterior  circumflex  artery, 

97.  Posterior  circumflex  artery  and  axillary  nerve, 

98 .  Subscapular  artery  and  nerves,    . 

99.  Thoracico-dorsalis  artery,    . 

100.  Circumflexa  scapulae  artery, 

c.  Arm, 

101 .  Brachial  artery,   .... 
103.   Deep  brachial  artery,   . 

103.  Superior  collateral  ulnar  artery, 

104.  Inferior  collateral  ulnar  artery,  . 

105 .  Median  nerve, 

106.  Ulnar  nerve, 

107.  Radial  nerve, 

108.  Musculo-cutaneous  nerve,' 

d.  Elbow   Region, 

109.  Brachial  artery,   . 

110.  Median  nerve, 

111.  Ulnar  nerve, 

112.  Radial  nerve, 

e.  Forearm — Volar  Surface, 

113.  Radial  artery, 

114.  Ulnar  artery, 

115.  Interosseal  artery, 

116.  Median  nerve, 

117.  Cutaneus  palmaris  nerve, 

118.  Interosseus  nerve, 
Radial  and  ulnar  nerves,  see  Radial  and  ulnar  arteries. 
Incisions  on  the  volar  side, 

/.  Forearm — Dorsal  Surface, 

119.  Deep  branch  of  the  radial  nerve. 
Incisions  on  the  dorsal  surface,    . 


CONTENTS. 


Vll 


g.  Wrist  Joint — Volar  Side, 

120.  Ulnar  artery  at  the  pisiform  bone, 

121.  Median  nerve 

h.  The  Hand — Dorsal  Side, 

122.  Radial  artery  on  the  dorsum  of  the  hand, 
133.  Radial  artery  on  the  trapezium, 

124.  Dorsal  branch  of  the  ulnar  nerve, 

125.  Dorsal  branch  of  the  radial  nerve, 
i.  The  Palm  of  the  Hand,    . 

126.  Superficial  volar  arch, 

127.  Deep  volar  arch, 

128.  Median  nerve, 

129.  Comon  digital  arteries, 
j.  Fingers,     ..... 

S.     Lower  Extremity,        .... 
Gluteal  Region,  ..... 
131.  Superior  gluteal  artery, 
Superior  gluteal  nerve, 
182.  Inferior  gluteal  (sciatic)  artery, 

133.  Posterior  femoral  cutaneous  nerve, 

134.  Sciatic  nerve, 

135.  Internal  pudendal  artery. 
Internal  pudendal  nerve. 

Inguinal  Region,  .... 

136.  External  iliac  artery, 

137.  Inferior  epigastric  artery  at  its  origin, 

138.  Circumflexa  ilii  artery  at  its  origin, 

139.  Inferior  epigastric    artery  at    the    anterior 

wall, 

140.  Circumflexa  ilii  artery  in  its  outer  third, 

141.  Aorta  and  common  iliac  artery, 

142.  Internal  spermatic  vessels, 

143.  Ureter,         .... 

144.  Inferior  mesenteric  artery, 

145.  Hypogastric  artery,    . 

146.  Obturator  artery, 

147.  Obturator  nerve. 
The  Thigh, 

148.  Femoral  artery, 

149.  Superficial  artery  of  the  knee  joint, 
Deep  femoral  artery. 
External  circumflex  femoral  artery, 

150.  Deep  artery  at  the  adductor  longus, 

151.  Internal  circumflex  artery, 

152.  Crural  nerve,       .... 

153.  Internal  saphenus  nerve,    . 

154.  Lateral  cutaneous  femoral  nerve, 

155.  Sciatic  nerve,     .... 
Region  of  the  knee  joint,    . 

156.  Popliteal  artery. 


abdominal 


PAGE 

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.  160 
.  161 
.  161 
.  161 
.  161 
.  162 
.  162 
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.  165 
.  165 
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.  167 
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.  168 
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.  170 

170 
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173 
173 
173 
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177 
180 
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181 
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181 
184 
184 
184 


Vlll 


CONTENTS. 


PAGE 

157. 

Peroneal  nerve, 185 

158. 

Internal  saphenus  nqrve  (see  Leg) . 

159. 

Communicating  peroneal  nerve  (external  sural) ,      .         .  185 

The  Leg, 

.  185 

160. 

Tibialis  antica  artery,         .    .     . 

.  185 

161. 

Deep  peroneal  nerve, 

.  186 

162. 

Superficial  peroneal  nerve, 

.  188 

163. 

Tibialis  postica  artery, 

.  188 

164. 

Tibio-peroneal  trunk. 

.190 

165. 

Peroneal  artery. 

.  193 

166. 

Internal  saphenus  nerve,    . 

.  194 

167. 

External  sural  and  external  saphenus  nerves. 

.  194 

168. 

Tibialis  posticus  nerve. 

.  195 

169. 

Suralis  medius  nerve, 

.   195 

The  Foot 

.  195 

170. 

Plantar  arch,       .... 

.  195 

171. 

Internal  plantar  artery, 

.  195 

173. 

Internal  plantar  nerve. 

.   196 

173. 

External  plantar  artery,     . 

.  196 

174. 

External  plantar  nerve. 

.  196 

175. 

Plantar  arteries  at  their  origin. 

.  196 

176. 

Dorsalis  pedis  artery, 

PAET  III. 

.   196 

Excisions  (Resections)  . 

T.     General  Observations, 199 

U.    Lower  Extremity, 300 

177.  Excision  of  the  phalanges  of  the  toes  and  the  metatarsal 

bones, 300 

Metatarso- tarsal  and  anterior  tarsal  resection,  .         .  201 

Intertarsal  resection,  .......  303 

Excision  of  the  talus,  .......  303 

Excision  of  the  calcaneus,  ......  205 

183.  Talo- calcaneus  and  posterior  tarsal  resection,   .         .         .  305 
183.  Resection  of  the  foot,  .         .         .        .         .        .         .306 

Total  tarsal  resection, .  209 

Resection  of  the  lower  third  of  the  leg,      ....  210 

Resection  of  the  tibia,         .......  211 

Resection  of  the  fibula,       .         .         .         .         .         .         .211 

Arthrotomy  and  resection  of  the  knee,      ....  213 

189.  Resection  of  the  patella,     .         .         .         .         .         .         .  318 

190.  Osteotomy  and  resection  of  the  tibia,         ....  318 

191.  Supracondylic  osteotomy  of  the  femur,      ....  219 
193.  Osteotomy  and  subtrochanteric  cuneiform  resection  of 

the  femur,      .........  319 

193.  Resection  of  the  diaphysis  of  the  femur,   ....  220 

194.  Resection  of  the  hip, 231 

195.  Resection  of  the  pelvis,       .......  225 


178. 
179. 
180. 
181. 


184, 
185, 
186 

187 
188, 


CONTENTS. 


IX 


Upper  Extremity, 

196.  Resection  of  the  fingers  and  metacarpals, 

197.  Resection  of  the  hand,        .... 

198.  Resection  of  the  ulna,         .... 

199.  Resection  of  the  radius,      .... 

200.  Resection  of  the  elbow 

201.  Resection  of  the  diaphysis  of  the  liumerus, 

202.  Resection  of  the  articulation  of  the  humerus, 

203.  Resection  of  the  clavicle,  .... 

204.  Resection  of  the  scapula,    .... 


PAGE 

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.  227 
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.  231 
.  232 
.  236 
.  237 
.  243 
.  244 


PART  IV. 

Amputations  and  Exarticulations. 


W. 
X. 


Y. 


Introduction 

Lower  Extremity,        ....... 

205.  Amputation  of  the  toes  and  metatarsals, 

206.  Exarticulation  of  the  toes, 

207.  Metatarsal  amputation, 

208.  Metatarso-tarsal  exarticulation, 

209.  Anterior  intertarsal  exarticulation,  . 

210.  Posterior  intertarsal  exarticulation, 

211.  Tarsal  amputation,     .... 
212a.  Subastragaloid  exarticulation, 

b.  Osteoplastic  subastragaloid  amputation, 

213.  Exarticulation  of  the  foot, 

214.  Osteoplastic  amputation  of  the  foot, 

215.  Amputation  of  the  leg, 

216.  Exarticulation  of  the  knee, 

217.  Amputation  of  the  femur, 

218.  Intracondylic  amputation  of  the  femur, 

219.  Supracondylic  amputation  of  the  femur, 

220.  Osteoplastic  supracondylic  amputation  of  the  femur, 

221.  High  amputation  of  the  femur, 

222.  Exarticulation  of  the  hip. 
Upper  Extremity, 

223.  Amputation  of  the  fingers  and  metacarpals, 

224.  Exarticulation  of  the  hand, 

225.  Amputation  of  the  forearm, 

226.  Exarticulation  of  the  elbow, 

227.  Amputation  of  the  arm, 

228.  Exarticulation  of  the  humerus, 

229.  Exarticulation   of   the  humerus  with  the  clavicle 

scapula,     ........ 


247 
254 
254 
254 
255 
256 
257 
257 
258 
259 
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260 
261 
263 
264 
265 
265 
266 
266 
267 
267 
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270 
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273 
273 
275 
276 


and 


OPERATIVE    SURGERY. 


PART  I. 

GENERAL   OBSEEVATIONS. 

A.  Introduction. 

Thanks  to  the  antiseptic  treatment  of  wounds,  we  can  cause 
the  most  rapid  heahng  by  adhesion  of  wounds  made  by  us  as 
surgeons,  and  since  then  operative  technique  has  received  an 
extraordinary  impulse.  Provided  we  are  sure  of  our  antisepsis, 
we  may  incise  any  part  of  the  body,  not  only  for  therapeutic 
but  also  for  diagnostic  purposes.  Of  course,  this  makes  it  in- 
cumbent upon  us,  now  that  the  indications  for  the  operative 
treatment  of  diseases  have  been  greatly  extended,  to  perfect  our 
technique  to  the  utmost,  so  as  to  remain  true  to  the  first  prin- 
ciple of  therapeusis:  "?w7^ocere."  A  complete  mastery  of  the 
technique,  resting  mainly  on  the  most  accurate  knowledge  of 
anatomy,  is  therefore  a  condition  sine  qua  non  in  operative 
therapeutics,  standing  next  to  the  reliability  of  the  antiseptic 
treatment  of  wounds.  In  practice  it  is  not  possible  to  study 
anatomical  handbooks  and  atlases  before  every  operation,  par- 
ticularly because  these  auxiliaries  are  for  the  most  part  based 
on  purely  anatomical  points  and  fail  to  notice  details  in  a  man- 
ner desired  by  the  surgeon.  For  this  reason  it  is  not  our  in- 
tention to  swell  the  number  of  the  many  excellent  text-books 
on  operative  surgery  by  another  more  explicit  one ;  on  the  con- 
trary, we  mean  to  give  the  briefest  possible  directions,  in  the 


2  OPERATIVE   SURGERY. 

manner  of  Eoser's  favorite  vade-mecum,  for  a  rapid  posting  on 
an  operation  to  be  performed. 

These  directions  may  serve  as  a  guide  for  practice  on  the 
cadaver,  but  the  main  purpose  has  been  to  adapt  them  to  the 
performance  of  operations  on  the  living  patient,  and  the  author, 
therefore,  has  recommended  only  those  methods  which  he  has 
tried  and  proved  by  many  years'  clinical  experience.  He  has 
done  so,  not  because  he  places  his  methods  above  those  of  other 
surgeons,  which  often  differ,  but  he  hopes,  on  the  contrary,  at 
some  future  time  to  fill  the  gaps  left  here,  by  doing  justice  to 
the  originators  of  operations  described  in  these  pages  and  of 
such  as  differ  from  them,  and  he  craves  indulgence  that  in  this 
first  publication  too  little  notice  has  been  taken  of  the  historical 
development  and  importance  of  the  various  methods. 

The  most  important  task  of  a  surgical  text -book  applicable 
to  the  living  patient  appears  to  us  to  be  that  the  reader  be 
enabled  to  post  himself  rapidly  and  surely  regarding  the  path 
the  knife  has  to  follow  in  incisions  in  any  part  of  the  body  and 
to  any  depth  desired. 

The  correct  direction  of  the  first  incision,  so  as  to  give  free 
access  on  the  one  hand,  and  positively  to  avoid  any  unnecessary 
incidental  injury  when  proceeding  deeper  on  the  other  hand,  is 
the  most  important  point  in  surgical  interference.  It  is  espe- 
cially necessary  to  learn  to  avoid,  besides  the  vessels  whose 
injury  is  manifested  by  hemorrhages,  the  larger  and  smaller 
nerve  twigs ;  in  other  words,  to  choose  the  border  lines  of  nerve 
distributions  for  incisions. 

In  this  sense  we  hold  certain  incisions  as  typical  for  definite 
regions  of  the  body,  that  is  to  say,  as  alone  admissible  when  the 
choice  of  the  method  is  left  free,  and  we  ourselves  claim  the 
value  of  our  contributions  to  lie  in  our  having  given  simple 
rules  for  reliable  and  conservative  surgical  manipulations  for 
every  part  of  the  body. 

A  second  group  of  operations  is  formed  by  excisions  or  resec- 


INTRODUCTION.  3 

tions.  In  these  the  object  is  not  only,  as  in  the  case  of  incisions, 
to  reach  a  deep  structure  by  the  shortest  road,  but  a  portion 
or  an  entire  organ  is  to  be  removed  from  the  body;  hence 
the  field  must  be  so  exposed  that  the  part  to  be  removed  is  eas- 
ily visible  and  palpable,  so  that  the  morbid  portion  can  be  safely 
and  readily  extracted. 

Eesections  of  the  joints  and  bones  form  a  type  of  excisions; 
with  them,  of  course,  we  may  group  also  extirpations  of  inter- 
nal organs  and  tumors. 

Finally,  in  a  third  group  we  have  to  deal  with  the  total 
removal  of  a  terminal  portion  of  a  part  of  the  body,  either  lim- 
ited or  extensive.  These  operations  are  called  amputations.  In 
these  we  have  an  added  factor  in  the  technique,  namely,  to  give 
that  part  of  the  body  from  which  a  portion  has  been  removed  a 
definite  form  and  a  covering  of  integument ;  for  by  the  complete 
loss  of  the  parts  on  the  one  side  of  the  wound  the  measures  for 
obtaining  a  rapid  adhesion  of  the  injured  tissues  become  more 
complicated. 

In  incisions,  no  matter  how  deep,  it  is  sufficient — antiseptic 
treatment  being  presupposed — to  bring  the  tissues  which  have 
been  separated  again  into  the  mutual  contact  that  existed  before 
the  operation. 

In  excisions  and  still  more  in  amputations,  however,  tissues 
come  in  contact  which  before  were  not  in  juxtaposition. 

In  incisions  the  application  of  simple  sutures  through  the 
entire  depth  and  width  of  the  raw  surfaces  suffices  to  bring 
them  again  into  the  closest  contact  as  before  the  operation. 
This  is  best  secured  by  a  continuous  suture,  the  needle  being 
passed  alternately  deeply  and  superficially. 

In  excisions  and  amputations  it  is  not  possible  by  sutures  to 
bring  the  raw  surfaces  so  close  that  the  tissues  belonging  to- 
gether are  brought  into  direct  contact. 

We  have  omitted  all  reference  to  the  choice  and  form  of  the 
instruments,  the  manipulation  of  knife,   forceps,  scissors,  saw, 


4  OPERATIVE   SURGERY. 

and  the  various  methods  of  suturing.  We  are  convinced  that 
no  directions,  no  matter  how  minute,  suffice  to  make  a  surgeon ; 
all  these  numerous  details  can  only  be  learned  by  witnessing 
and  practising  them  in  clinics  and  hospitals  under  skilful  in- 
struction. In  like  manner  the  facts  as  to  when  and  why  ves- 
sels are  to  be  ligated,  nerves  to  be  stretched,  joint  capsules  to 
be  laid  open,  articulations  to  be  resected,  and  limbs  to  be  ampu- 
tated— in  a  word,  the  discussion  of  the  indications  for  the  oper- 
ations— must  be  learned  in  the  clinic. 

As  we  write  these  instructions  mainly  for  use  on  the  living 
patient  we  cannot  omit  mention,  by  way  of  introduction,  of  two 
vital  conditions  in  every  operative  manipulation,  namely,  anaes- 
thesia and  antisepsis.  It  is  not  permitted  to  give  pain  to  a  per- 
son by  an  operation,  any  more  than  to  jeopardize  life  by  the 
inoculation  of  infectious  material  into  the  wound. 

B.  Anaesthesia. 

The  anaesthesia  of  a  patient  differs  widely  according  to  the 
operation  to  which  he  is  to  be  subjected.  We  shall  describe 
only  those  measures  of  whose  efficacy  and  mode  of  application 
we  are  qualified  to  speak  from  personal  observation  and  experi- 
ence. 

Ideal  ansesthesia  would  be  approached  if  we  could  render  in- 
sensitive only  that  part  of  the  body  which  is  to  be  operated  on. 
While  there  are  measures  which  fulfil  this  indication,  they  act 
only  superficially  and  for  a  brief  period. 

Local  Ancesthesia. 

The  most  important  local  anaesthetics  are  ether  spray  and 
cocaine  injections.  The  two  drugs  differ  in  their  value;  one 
having  a  purely  physical  effect,  while  the  other  acts  chemically 
or  as  a  poison,  not  only  on  the  sensory  nerves,  but  also  on  other 
parts  of  the  nervous  system,  by  absorption,  thus  possibly  giving 


ANESTHESIA.  5 

rise  to  dangerous  incidental  effects.  In  the  use  of  ether,  con- 
duction along  the  sensory  nerves  is  inhibited  by  cold.  This 
method  of  anaesthesia  is  suitable  for  minor  operations  of  brief 
duration.  But  the  effect  of  ether  continues  for  a  short  time 
only.  If  ether  spray  is  made  to  act  for  a  longer  time  on  the 
skin  the  latter  may  become  necrotic,  especially  in  the  case 
of  small  tumors  over  which  the  skin  is  tense  (chondroma  of  the 
finger).  Local  anaesthesia  by  ether  spray  may  be  used  when 
the  most  painful  part  of  the  operation  consists  in  the  lesion  of 
the  integument,  as  in  simple  incisions  or  avulsion  of  a  nail.  In 
such  cases  it  is  one  of  the  best  measures  in  our  possession.  The 
only  drawback  is  the  burning  sensation  when  the  tissue  thaws. 
To  avoid  this  subsequent  pain  the  part  should  be  dipped  in  warm 
water. 

In  most  recent  times,  in  place  of  ether  spray,  ethyl  chloride, 
which  acts  more  rapidly  and  certainly,  has  been  used.  This  is 
vaporized  by  the  heat  of  the  hand. 

Cocaine,  in  the  form  of  the  hydrochlorate,  injected  into  the 
tissues  inhibits  the  conduction  in  the  sensory  nerves,  even  the 
larger  trunks.  It  also  acts  through  the  intact  mucous  mem- 
brane on  which  it  is  painted,  without  being  injected  into  the 
tissues.  This  drug  has  disadvantages  as  compared  with  ether, 
because  it  is  absorbed  and  may  paralyze  distant  nerve  elements ; 
hence  it  is  to  be  used  only  under  certain  conditions.  For  injec- 
tion it  is  used  in  one-per-cent  solution ;  for  painting,  in  ten-per- 
cent strength.  Its  effect  lasts  only  a  few  minutes.  Experience 
has  shown  that  a  dose  of  but  1.5  grains  may  cause  untoward 
accidents.  A  dose  above  8  grains  may  be  fatal.  Hence  several 
syringefuls  of  a  one-per-cent  solution  may  be  injected  without 
fear.  Of  course,  regard  must  be  had  for  antisepsis;  therefore 
the  cocaine  is  mixed  with  a  five-per-cent  solution  of  carbolic 
acid.  The  solution  must  be  injected  directly  into  the  cutis  or 
immediately  beneath  it  at  the  point  where  the  tissues  are  to  be 
severed.     In  intracutaneous  injections  the  anaesthetic  zone  is 


6  OPERATIVE   SURGERY. 

recognized  by  the  small  elevation  produced.  Minor  operations, 
incisions,  and  excisions  of  small  tumors  may  be  performed  by 
means  of  cocaine  without  producing  any  pain. 

General  Ancesthesia. 

Our  knowledge  of  this  beneficent  means  dates  back  only  to 
the  fourth  decade  of  this  century.  The  first  drug  by  means  of 
which  general  anaesthesia  was  obtained  was  ether.  A  very  few 
years  later  it  was  displaced  by  chloroform.  Up  to  the  present 
time  it  is  not  decided  which  of  these  two  drugs  is  deserving  of 
more  general  application.  We  therefore  think  it  desirable  to 
inform  the  reader,  on  the  strength  of  our  own  experience,  as  to 
what  appears  to  us  to  be  the  most  judicious  mode  of  employ- 
ment of  these  two  agents;  for  the  fact  that  competent  surgeons 
advocate  opposite  opinions  proves  that  both  drugs  may  be  judi- 
ciously used  according  to  the  conditions  present. 

The  difference  in  the  mode  of  employment  of  the  two  drugs 
is  considerable  in  so  far  as  ether  is  poisonous  only  in  much 
larger  doses  than  chloroform.  In  the  larger  doses  both  drugs 
have  a  toxic  effect.  With  neither,  therefore,  may  we  exceed 
a  certain  maximum  dose,  as  with  every  other  poison.  This 
maximum  dose  is  much  greater  with-  ether ;  the  proportion  being 
about  like  that  between  quinine  and  strychnine.  Just  as  we 
employ  quinine  in  much  larger  doses  than  morphine  and  strych- 
nine, so  we  can  give  much  more  ether  than  chloroform.  Herein 
lies  the  great  advantage  of  ether ;  for  in  employing  anaesthesia 
it  is  necessary  to  give  the  largest  possible  dose  of  the  two  drugs 
in  the  shortest  time.  As  is  well  known,  morphine  can  be  given 
in  quantity  greatly  exceeding  the  maximum  if  the  doses  are 
distributed  over  a  longer  time.  In  the  same  way  more  chloro- 
form and  ether  may  be  used  in  an  operation  lasting  five  hours 
than  could  be  employed  in  a  shorter  time.  But  the  danger  of 
exceeding  the  limit  at  a  single  dose  is  much  greater  with  chloro- 


ANESTHESIA.  7 

form  than  with  ether.  Why  then  is  chloroform  not  discarded 
entirely? 

Ether  has  certain  contra -indications.  By  its  local  irritating 
effect  on  the  mucous  membranes  of  the  respiratory  organs  it 
causes  congestion,  swelling,  and  increased  secretion  of  mucus. 
For  this  reason  ether  is  not  admissible  in  all  cases  where  there 
is  hypersemia  or  catarrh  of  the  air  passages,  especially  if  asso- 
ciated with  dyspnoea.  The  second  reason  against  the  exclusive 
use  of  ether  is  that,  being  effective  only  in  large  doses,  it  takes 
longer  to  produce  anaesthesia  if  given,  like  chloroform,  in  slowly 
increasing  amounts.  This  causes  a  much  prolonged  and  more 
intense  stage  of  excitement.  In  order  to  avoid  this  drawback 
ether  requires  a  large  initial  dose.  In  this  way  ansesthesia  is 
very  quickly  produced,  as  early  as  by  chloroform  if  not  sooner. 
For  the  same  reason,  when  a  rapid  ether  ansesthesia  is  desired, 
we  need  special  large  masks  which  cover  the  face  completely, 
because  the  ether  vapors  must  be  quickly  inhaled,  in  a  concen- 
trated condition. 

In  addition  the  mask  is  usually  covered  with  a  towel ;  we 
adapt  to  the  face  of  the  patient  a  ring  of  flexible  copper  wire  so 
as  to  exclude  the  air  as  much  as  necessary.  In  this  way  it  is 
possible  to  produce  ether  ansesthesia  in  two  or  three  minutes  and 
the  stage  of  excitement  is  greatly  shortened.  This  rapid  method, 
however,  has  the  drawback  that  the  necessary  exclusion  of  the 
air  causes  a  certain  degree  of  asphyxia.  This  explains  the  alarm- 
ing sensations,  cyanosis  of  the  face,  and  the  heavy  breathing  of 
many  patients  under  its  influence. 

With  chloroform  such  measures  for  the  rapid  and  concen- 
trated introduction  of  the  drug  are  unnecessary.  On  the  con- 
trary, care  is  taken  to  admit  sufficient  air.  For  years  we  have 
arranged  it  so  that  a  free  space  is  left  all  around  between  the 
cover  of  the  mask  and  the  ring  which  is  moulded  to  the  face 
(Fig.  1),  In  this  way  sufficient  ansesthesia  is  produced  within 
ten  minutes  at  the  most,  without  any  obstructed  respiration  or 


8  OPERATIVE   SURGERY. 

sensation  of  suffocation.  This  is  one  advantage  of  chloroform. 
Moreover,  chloroform  has  no  such  irritating  effect  on  the  mucous 
membranes  as  ether ;  hence  chloroform  anaesthesia  is  more  quiet 
and  agreeable  than  that  of  ether.  A9  a  matter  of  course,  in 
employing  a  drug  intended  to  inhibit  sensation  and  in  many- 
cases  also  to  produce  a  paralysis  of  the  motor  apparatus  to  the  de- 
gree of  muscular  relaxation,  care  must  be  taken  that  the  func- 
tion of  the  respiratory  and  circulatory  organs  is  not  likewise 
suspended.  The  first  task  after  beginning  muscular  relaxation 
is  to  make  sure  of  respiration,  particularly  the  ingress  of  air  into 


Fig.  1. 


the  opening  of  the  larynx.  This  is  effected  by  lifting  the  max- 
illa, and  with  it  the  root  of  the  tongue,  forward.  As  soon  as  the 
stage  of  paralysis  begins  the  tongue  and  the  maxilla,  in  the 
usual  dorsal  position,  drop  backward  and  the  epiglottis  overlaps 
the  laryngeal  opening  like  a  valve,  as  we  may  convince  ourselves 
by  inspection  during  resections  of  the  jaw  and  the  tongue.  It  re- 
quires strong  forward  traction  of  the  base  of  the  tongue  or  the 
epiglottis  to  render  the  upper  portion  of  the  latter  so  tense  that 
it  remains  fixed  above  and  forward  during  inspiration.  Pres- 
sure behind  both  maxillary  angles  is  best  adapted  to  raise  the 
base  of  the  tongue  along  with  the  jaw,  provided  the  neck  be 
stretched  at  the  same  time  by  bending  the  head  backward,  thus 
making  the  tongue  tense  not  only  forward  but  also  upward. 
This  stretches  the  glosso-epiglottic  ligaments  and  the  epiglottis 
is  held  fast.  This  manipulation  positively  prevents  accidental 
suffocation  during  anaesthesia.     Previous  to  it  the  patient  must 


ANESTHESIA.  9 

be  prepared  so  that  respiration  be  not  hindered  by  other  causes, 
as  by  full  stomach  and  intestines,  constricting  clothing,  or  im- 
proper position.  At  the  beginning  of  the  anaesthesia  the  stom- 
ach must  be  empty  or  have  been  artificially  emptied,  lest  rem- 
nants of  food  get  into  the  larynx  from  vomiting  during  sleep. 

If  free  respiration  before  and  during  anaesthesia  is  provided 
for  in  this  manner ;  if  a  mask  is  employed  which  makes  it  im- 
possible that  concentrated  chloroform  be  inhaled;  and  if  the 
amount  of  chloroform  in  the  continually  admitted  fresh  air  is 
increased  by  an  uninterrupted  addition  of  the  drug,  drop  by  drop, 
in  quantity  just  sufficient  to  produce  anaesthesia,  then  there  is 
no  danger,'  but  this  becomes  imminent  when  more  profound 
effects  on  the  nervous  system  are  aimed  at,  namely,  complete 
muscular  relaxation,  and  when  the  chloroform  is  given  for  a 
longer  period.  In  this  way  the  maximum  dose  is  necessarily 
more  and"  more  approached,  and  we  should  be  able  to  recognize 
the  signs  of  this  approach.  They  are  as  follows :  the  dropping 
of  the  jaw  and  tongue  with  the  consequent  obstructed  respira- 
tion indicate  the  beginning  of  the  more  profound  effect ;  then  it 
is  shown  by  the  general  muscular  relaxation  and  the  slowing  of 
the  pulse.  The  maximum  is  almost  reached  when  respiration 
becomes  labored,  while  the  pulse  becomes  irregular  and  weaker. 
This  shows  sinking  of  the  blood  pressure,  which  may  be  followed 
at  any  moment  by  insufficient  heart  action,  with  the  resulting 
cerebral  anaemia  and  collapse.  It  is  necessary  to  guard  against 
this  possibility  beforehand  by  placing  the  patient  in  a  position 
which  favors  the  cerebral  circulation.  A  patient  should  be 
chloroformed  only  with  the  trunk  in  a  horizontal  position  and 
the  lower  extremities  raised.  In  our  operating  table  provision 
has  been  made  to  have  the  legs  higher  than  the  trunk.     Of 

'  We  have  never  been  able  to  make  up  our  minds  to  employ  the  much- vaunted 
apparatus  of  Junker  and  Kapi^oler,  not  only  because  the  anfesthesia  is  rendered 
more  complicated,  but  because  we  find  tliat  vrith  careful  supervision  the  dose 
can  be  mucli  better  adapted  to  individual  conditions  by  adding  the  chloroform 
drop  by  drop  than  by  means  of  apparatus. 


10  OPERATIVE   SURGERY. 

course  the  administration  of  the  anaesthetic  is  to  be  stopped  as 
soon  as  the  above-mentioned  dangerous  symptoms  appear. 

In  every  prolonged  operation  v^e  advise,  after  complete  anaes- 
thesia has  been  obtained  by  chloroform,  to  continue  with  ether 
unless  contra -indicated  by  disease  of  the  air  passages.  The 
maximum  dose  of  ether  is  so  much  greater  than  that  of  chloro- 
form that  the  danger  of  reaching  that  point  suddenly  is  incom- 
parably less  than  v^ith  chloroform.  It  is  not  difficult  to  maintain 
for  hours  v^ith  ether  an  anaesthesia  once  completely  effected  b}'" 
chloroform,  and  this  combined  method  has  the  great  advantage 
that  the  ether  need  not  be  given  in  suffocating  doses,  since  small 
doses  and  ordinary  masks  suffice.  But  for  economical  reasons 
it  is  always  well  to  guard  against  the  too  rapid  evaporation  of 
the  ether  by  covering  the  mask  with  impermeable  tissue. 

In  disease  of  the  heart  muscle  chloroform  must  never  be 
given,  but  only  ether. 

For  an  anaesthesia  of  brief  duration  bromide  of  ethyl  is  an 
excellent  drug :  five  drachms  poured  at  once  on  an  impermeable 
mask,  and  pressed  on  mouth  and  nose  while  air  is  excluded,  will 
in  from  thirty  to  sixty  seconds  cause  an  anaesthesia  which  lasts 
from  one  to  several  minutes.  But  nothing  more  should  be  at- 
tempted with  this  drug,  neither  prolonged  anaesthesia  nor  mus 
cular  relaxation ;  bromide  of  ethyl  should  not  be  poured  on  ^ 
second  time  because,  owing  to  its  quick  effect,  sinking  of  the 
blood  pressure  with  consequent  collapse  may  ensue  with  surpris- 
ing rapidity.  Recent  experience  seems  to  show  that  bromide  of 
ethyl  anaesthesia  may  be  effected  with  very  small  doses  of  from 
80  to  100  minims  if  it  is  poured  on  drop  by  drop,  and  that  the 
narcosis  can  then  also  be  maintained  for  a  longer  time,  fifteen 
to  twenty  minutes,  without  any  danger. 

Chloride  of  methylene  is  preferred  to  both  chloroform  and 
ether,  as  being  much  less  dangerous,  by  such  an  authority  as 
Spencer  Wells.  But  as  this  drug  is  given  by  Spencer  Wells,  or 
by  Junker  von  Langegg,  the  inventor  of  the  Junker  apparatus, 


THE   TREATMENT   OF   WOUNDS.  11 

only  by  means  of  the  latter,  it  is  possible  that  the  excellent  re- 
sults obtained  are  due  as  much  to  their  great  experience  in  its 
administration  as  to  its  chemical  composition.  Our  experi- 
ence with  it  has  been  unsatisfactory,  probably  owing  to  its 
inconstant  chemical  composition. 

It  is  proper,  and  we  have  done  so  for  nearly  twenty  years,  to 
administer  one-half  hour  prior  to  every  anaesthesia  a  cup  of  tea 
with  brandy  or  a  glass  of  Marsala  wine  in  order  to  strengthen 
the  action  of  the  heart  and  raise  the  blood  pressure.  We  are 
able  to  prove  by  pulse  tracings  the  influence  exerted  under  an- 
aesthesia by  these  stimulants  in  this  direction. 


C.  The  Treatment  of  Wounds. 

The  second  indication  we  have  to  meet  during  every  opera- 
tion is  asepsis.  We  must  guard  the  patients  both  during  and 
after  the  operation  against  the  injury  and  danger  of  a  wound 
infection. 

It  is  not  to  be  expected  that  an  exhaustive  treatment  of  this 
subject  will  be  given  within  a  couple  of  pages.  In  this  place 
we  mean  only  to  explain  the  principles  underlying  this  treat- 
ment of  wounds,  and  how  a  rapid  and  undisturbed  healing  of 
every  operative  wound  can  be  simply  secured  by  excluding  in- 
fection. When  a  wound  is  to  be  healed  quickly  it  must  be 
guarded  against  infection,  that  is  to  say,  against  the  deposition 
and  development  of  the  agents  of  decomj)Osition.  The  truth  of 
the  fact  may  be  considered  as  demonstrated  that  every  wound, 
with  proper  care  for  favorable  mechanical  conditions,  may  be 
caused  at  once  to  adhere,  provided  micro-organisms  and  their 
products  are  kept  from  the  tissues.  Micro-organisms,  however, 
adhere  to  all  solid  and  liquid  objects  which  come  in  contact  with 
the  wound  and  must  be  destroyed  upon  and  within  them. 

Near  the  end  of  the  sixth  decade  of  this  century.  Lister  dem- 
onstrated the  decisive  importance  of  atmospheric  dust   and  all 


12  OPERATIVE   SURGERY. 

objects  touched  by  it,  and  he  introduced  the  principle  of  the  an- 
tiseptic treatment  of  wounds,  based  on  Pasteur's  proof  of  the 
origin  and  nature  of  the  causes  of  decomposition  in  general. 
Lister  first  proved,  that  decomposition  in  wounds  occurs  only 
when  particles  of  dust  are  brought  in  contact  with  them.  Should 
these  noxious  particles  be  kept  off,  no  decomposition  occurs. 
The  splendid  results  immediately  obtained  in  surgery  by  having 
regard  to  this  simple  fact,  both  in  the  hands  of  Lister  and 
particularly  in  those  of  German  surgeons  (Volkmann,  Schede, 
Thiersch,  and  Socin),  form  the  basis  of  the  extraordinary  im- 
portance of  Lister's  investigations  and  observations.  The 
second  step  taken  by  Lister  was  his  demonstration  that  these 
dust  particles  are  of  an  organic  nature,  since  they  could  be  de- 
stroyed by  such  measures  as  destroy  organic  substances  in  gen- 
eral. Finally  Lister  proved  that  these  substances  are  capable 
of  development,  that  is  to  say,  that  they  are  organized. 

Pasteur  had  furthermore  found  some  definite  germs  for  cer- 
tain decompositions  outside  of  the  human  body.  Billroth  had 
published  in  a  remarkable  work  the  results  of  his  investigation 
on  the  specific  material  of  wound  infection.  But  it  was  only 
toward  the  end  of  the  seventh  decade  that  Koch  proved  by 
means  of  greatly  improved  auxiliaries  that  in  wounds  as  in  fluids 
contained  in  glass  flasks  certain  kinds  of  decomposition  occur 
only  through  the  influence  of  certain  micro-organisms.  Now 
the  victory  was  gained  upon  the  field  on  which  the  doctrine  of  the 
diseases  of  wound  infection  could  be  accurately  established  and 
on  which  even  to  the  present  day  ever  new  advances  are  made 
in  the  treatment  of  surgical  and  medical  diseases. 

For  the  treatment  of  wounds,  however,  one  preliminary 
standpoint  has  already  become  common  property,  namely,  that 
we  should  strive  to  exclude  all  micro-organisms  from  wounds 
and  that  we  possess  the  means  to  accomplish  this  object  in  prac- 
tice in  a  satisfactory  manner. 

Lister  believed  he  could  meet  this  indication  in  the  main  by 


THE   TREATMENT  OF   WOUNDS,  13 

preventing  atmospheric  infection,  and  the  spray  introduced  by 
him  remained  for  a  long  time  the  fundamental  point  of  the  anti- 
septic treatment  of  wounds.  The  operator  and  the  patient  were 
enveloped  in  a  dense  fog  of  carbolic  acid  which  was  to  penetrate 
the  dust  j)articles  and  render  them  innocuous. 

The  doctrine  of  atmospheric  infection  was  based  on  experi- 
ments in  which  decomposition  of  an  unstable  fluid  (urine)  was 
positively  prevented  for  years  when  the  drawn-out  neck  of  the 
vessel  was  bent  downward;  while  decomposition  ensued  im- 
mediately when  the  neck  of  the  bottle  was  broken.  It  has 
been  recently  shown  that  the  spray  is  not  only  unnecessary  but 
is  even  injurious  because  it  agitates  the  dust  particles  and  act- 
ually drags  the  germs  of  infection  along  upon  the  wound  with- 
out harming  them  or  arresting  their  development  by  the  tem- 
porary contact  with  the  carbolic  spray.  It  appeared  that  in 
order  to  prevent  atmospheric  infection  it  was  sufficient  to  re- 
move the  dust  particles  by  ventilation,  mechanically  by  washing 
the  walls  and  furniture,  and  finally  by  allowing  the  remaining 
dust  to  settle,  if  the  operation  is  performed  in  appropriate  locali- 
ties which  can  be  shut  off  and  have  smooth,  clean  walls.  Even 
Lister  has  proved  by  Tyndall's  beautiful  experiment  that  the 
air  becomes  perfectly  freed  from  dust  by  allowing  the  heavy 
particles  to  settle :  if  a  beam  of  sunlight  is  allowed  to  fall  through 
an  empty  closed  bottle  it  can  be  seen  as  a  bright  streak ;  but 
when  the  bottle  is  left  at  rest  the  streak  disappears  because 
the  dust  particles  which  reflected  the  light  have  fallen  to  the 
bottom. 

But  the  doctrine  of  the  relative  innoxiousness  of  atmospheric 
infection  must  not  be  carried  ad  absurclum  by  avowing  that  one 
would  as  readily  operate  in  any  by-place  as  in  an  operating-hall, 
provided  instruments  and  dressings  are  properly  disinfected. 
On  the  contrary,  it  must  always  be  considered  a  matter  of  great 
safety  when  an  operation  can  be  performed  in  a  room  with  clean, 
smooth  walls,  so  that  dust  can  neither  fall  nor  be  stirred  up  from 


14  OPERATIVE   SURGERY. 

furniture,  floor,  or  particularly  from  the  ceiling  or  possibly  a 
hanging  lamj). 

Of  vastly  greater  importance  indeed  than  an  atmospheric 
infection  is  that  form  which  at  present  is  preferably  designated, 
as  contact  infection.  It  is  this  upon  which  nowadays  the  great- 
est stress  is  laid  in  the  treatment  of  wounds,  even  by  Lister 
himself,  and  as  a  matter  of  fact  we  possess  a  true  antisepsis  only 
since  this  view  has  been  accepted.  This  is  the  infection  caused 
by  touching  wounds  with  larger  or  smaller  objects  of  any  kind 
— instruments,  sponges,  pledgets,  the  hands  of  the  surgeon,  and 
irrigating  fluids. 

It  is  at  once  clear  how  infectious  materials  introduced  in  this 
manner  must  adhere  to  the  surface  of  the  wound  in  quite  a  dif- 
ferent way  from  those  coming  from  the  air.  When  the  tissues  in 
the  wound  are  grasped  with  hands  or  instruments  the  infectious 
matters  are  at  the  same  time  pressed  into  it,  somewhat  as  in  vac- 
cination. The  term  "  infection  by  vaccination"  would  be  more  de- 
scriptive, inasmuch  as  air  infection  is  really  that  of  mere  contact. 

But  it  is  still  more  important  to  separate  another  mode  of 
infection,  namely,  that  for  which  we  have  proposed  the  name 
"infection  by  implantation." 

In  this  class  belong  in  the  first  place  infection  by  ligatures, 
and  in  the  second  place  by  other  bibulous  or  porous  foreign 
bodies.  If  infectious  germs  are  introduced  into  a  wound  with  a 
suture  we  infect  not  only  by  the  momentary  contact  or  vaccina- 
tion, but  we  transplant  into  the  wound  a  permanent  focus 
of  incubation  in  which  the  germs  at  once  find  an  appropriate 
place  of  development.  Within  such  a  foreign  body  (necrotic 
portions  of  tissue  which  have  been  infected  act  in  a  similar 
manner)  are  contained  the  most  favorable  conditions  for  a  last- 
ing and  spreading  infection,  which  is  by  no  means  the  case  to  a 
like  degree  in  infection  by  vaccination.  Hence  infection  by  im- 
plantation is  the  worst  of  all,  and  disinfection  must  pay  the 
greatest  attention  to  this  mode. 


THE   TREATMENT   OF   WOUNDS,  15 

Do  we  at  this  time  possess  the  means  of  positively  disinfect- 
ing or  sterilizing  all  those  objects  which  come  in  contact  with 
the  wound  or  remain  in  it?  This  question  is  to  be  answered 
unhesitatingly  in  the  affirmative  as  regards  pledgets,  dressings, 
sutures,  and  instruments,  and  a  physician  is  no  longer  permitted 
to  sin  against  the  demands  of  absolute  sterilization  of  the  ob- 
jects named  or  to  excuse  defects  in  the  antiseptic  treatment  of 
wounds  by  untoward  external  conditions. 

What  constitutes  correct  antisepsis?  There  is  a  whole  series 
of  drugs  possessing  disinfecting  power.  Foremost  stand  carbolic 
acid  and  the  still  more  reliable  corrosive  sublimate.  These  two 
drugs,  however,  do  not  act  instantaneously,  but  after  some  little 
time,  so  that  the  dressings  must  be  exposed  to  their  effect  for 
some  longer  period.  If  the  dressings  are  to  be  really  sterile, 
that  is  to  say,  if  all  germs  and  spores  are  to  be  killed  in  them, 
we  must  adapt  the  duration  of  the  influence  of  these  antiseptics 
to  the  resistance  of  the  most  refractory  spores.  There  are  mi- 
cro-organisms which  can  resist  even  sublimate  for  two,  three,  or 
four  hours,  perhaps  a  whole  day. '  We  must  leave  our  dressings 
in  the  respective  solutions  for  several  days,  but  this  would  injure 
many  materials.  Instruments  cannot  at  all  be  placed  in  subli- 
mate, nor  for  days  and  weeks  in  the  slowly  acting  carbolic  acid. 
Chemical  disinfection,  therefore,  finds  application  only  with  some 
materials,  especially  silk  ligatures.  These  can  be  kept  for  a  long 
time  in  sublimate  without  injury.  One  drawback  of  the  chemi- 
cal method  is  that  the  dressings,  when  brought  in  contact  with 
the  body  of  the  patient,  manifest  the  poisonous  effects  of  the 
drugs,  both  by  their  local  influence  and  by  absorption.  The 
chemical  mode  of  sterilization,  therefore,  is  but  a  makeshift  and 
applicable  only  to  certain  materials  and  under  certain  conditions.' 

'  Compare  among  others  the  investigations  by  Vicquerat  and  Zimmermann 
(under  Tavel's  direction),  Berne  Dissertation,  1889. 

'^  With  Tavel,  we  must  make  a  distinction  between  disinfection  and  sterili- 
zation ;  for  the  treatment  of  woiinds  we  may  be  satisfied  with  disinfection,  and 
restrict  sterilization  to  the  pathogenic  germs. 


16  OPERATIVE   SURGERY. 

The  dry  preservation  of  dressings  sterilized  with  solutions  of 
carbolic  acid  and  siablimate  is  to  be  entirely  rejected.  Steriliza- 
tion with  these  drugs  lasts  as  long  as  the  disinfectant  remains 
present  in  active  form.  Positive  demonstrations  show  that  this 
is  no  longer  the  case  with  dry  dressings.  Corpora  non  agunt 
nisi  liquida.  We  cannot  be  sure  that  during  the  preservation 
or  at  the  moment  of  their  use  infectious  germs  did  not  adhere 
to  such  dressings.  Chemical  sterilization,  therefore,  is  reliable 
only  v/hen  the  materials  are  applied  to  the  wound  directly  from 
the  disinfecting  fluids.  Before  applying,  the  materials  taken 
from  the  solutions  are  expressed  in  a  wringer  and  immediately 
placed  upon  the  wound.  All  dry  dressings,  supplied  ready  pre- 
pared by  the  factories,  should  not  be  recognized  as  sterilized. 

Ligatures  have  long  been  treated  according  to  this  view. 
These,  when  subjected  to  chemical  sterilization,  are  wound  upon 
spools  which  are  preserved  in  the  antiseptic  fluid,  from  which 
they  are  transferred  directly  to  the  wound.  This  is  admis- 
sible because  we  are  dealing  with  a  fine,  thin  substance  and 
the  small  amount  of  adhering  carbolic  acid  or  sublimate  is 
of  no  importance  with  reference  to  local  or  general  poisonous 
effect ;'  in  the  case  of  large  dressings  the  drawback  mentioned 
as  to  their  direct  application  from  the  disinfecting  fluid  remains 
in  force. 

Our  best  sterilizing  agent  is  heat.  With  a  degree  of  heat  of 
from  300  to  350°  F.  we  secure  satisfactory  sterilization  or  disin- 
fection of  all  our  dressings — gauze,  binders,  ligatures,  and  in- 
struments. Still  more  effective  than  this  dry  heat  is  moist  heat. 
Its  safest  mode  of  employment,  according  to  the  most  recent  in- 
vestigations, is  in  the  form  of  a  current  of  steam  under  high 
pressure.  This  at  266°  F.  and  above  destroys  all  micro-organ- 
isms and  their  spores  present  in  permeable  objects,  in  the  course 

^  Taking  the  ligatures  from  the  sublimate  solutions  during  the  operation  has 
the  advantage,  on  the  contrary,  that  it  guards  at  the  same  time  against  acci- 
dental infection  at  the  moment  of  employment. 


THE   TREATMENT   OF   WOUNDS.  17 

of  a  few  minutes.  At  our  clinic  we  use  a  steam  boiler  at  293° 
F.  under  pressure  of  three  atmospheres. 

But  even  this  perfectly  reliable  method  of  sterilization  is 
useless  unless  the  objects  can  be  directly  transferred  from  the 
boiler  to  the  wound.  This  is  not  possible  in  all  cases,  for  extra- 
neous reasons,  and  instruments  in  particular  suffer  more  from 
steam  than  from  dry  heat. 

The  best  and  simplest  substitute  for  steam  which  we  have 
used  extensively  for  years  is  boiling  of  the  instruments  and 
dressings.  The  boiling  must  be  continued  for  some  time;  but 
we  may  be  sure  of  working  with  disinfected  instruments  when 
they  have  remained  for  half  an  hour  in  boiling  water,  or  better, 
according  to  Schimmelbusch's  method,  in  one-per-cent  soda  solu- 
tion, in  which  the  instruments  do  not  rust.  Boiling  has  the 
great  advantage  that  the  necessary  apparatus  is  everywhere  ac- 
cessible and  particularly  can  be  so  placed  that  instruments  and 
dressings  can  be  taken  from  the  sterilizing  apparatus  directly 
by  the  hands  of  the  operator.  Quite  recently  Dr.  Tavel  has  ex- 
perimented with  solutions  of  table  salt,  and  table  salt  with  soda 
(we  have  used  the  former  for  a  long  time  in  place  of  plain  water 
for  wounds),  and  has  found  that  they  required  less  boiling  for 
complete  sterilization.  Dr.  TaveFs  favorable  report  shows  that 
a  solution  of  0.75^  of  table  salt  and  0.25;^  of  calcined  soda  is 
absolutely  sterile  after  fifteen  minutes'  boiling  (the  spores  of 
the  anthrax  and  hay  bacillus  and  of  the  bacillus  mes.  vulg.  are 
killed)  and  keeps  very  long  (a  few  mould  fungi  grow  only  after 
several  weeks).  Gauze  compresses,  pledgets,  and  silk  are  ab- 
solutely sterile  after  half  an  hour's  boiling  in  the  solution. 
Tavel  subjected  the  salt-and-soda  solution  to  a  special  examina- 
tion in  order  to  use  a  solution  containing  the  same  amount  of 
salt  and  alkali  as  the  blood.  As  regards  the  salt  solution  our 
experience  has  long  shown  that  it  does  not  irritate  the  wounds 
at  all.  According  to  Tavel  the  salt-and-soda  solution  is  also 
well  borne  in  large  doses  by  intravenous  injection,  nor  does  it 


18  OPERATIVE    SURGERY. 

injure  the  peritoneum  in  any  manner.  A  boiled  solution  of  salt 
and  soda  (Tavel's  0.75^  of  salt  and  0.25^  of  soda)  also  furnishes 
a  perfectly  sterile  and  unirritating  fluid  for  rinsing  and  cleans- 
ing wounds.  This  does  away  with  the  objection  against  the 
flooding  system  raised  by  the  advocates  of  the  dry  treatment  of 
wounds.  Warm  compresses  boiled  in  the  salt-and-soda  solution 
furnish  the  best  dressing  for  immediate  contact  with  the  wound. 
We  always  use  gauze,  deprived  of  fat  for  dressings,  pledgets 
of  gauze  in  place  of  sponges  for  soaking  up  liquids,  drainage 
tubes  of  glass,  and  silk  ligatures. 

Though  we  have  arrived  at  absolute  security  in  the  disin- 
fection by  relatively  simple  measures  (steaming  and  boiling)  of 
all  inanimate  objects,  this  is  not  true  in  like  manner  of  our 
hands  and  the  skin  and  tissues  of  the  patient.  Yet  the  cleans- 
ing of  hands  and  skin  is  an  indispensable  condition  of  the  anti- 
septic treatment  of  wounds.  We  cannot  hold  our  hands  in  the 
steam  nor  can  we  boil  or  scald  them.  Hence  we  must  resort  to 
chemical  measures  which  really  should  by  rights,  as  we  have 
shown,  act  for  hours.  As  this  is  impossible,  we  must  content 
ourselves  with  a  preliminary  thorough  mechanical  cleansing  as 
we  do  in  the  prevention  of  atmospheric  infection.  Some  days 
before  the  operation  the  skin  of  the  patient  is  shaved  over  a  large 
circumference,  scrubbed  with  soap  and  hot  water,  protected 
against  gross  impurities  by  dressings,  and  immediately  before 
the  operation  scrubbed  with  a  0.1^  sublimate  solution  and  rinsed 
with  an  abundance  of  water.  The  operator's  hands,  fingers, 
and  the  nails  particularly  are  washed  with  soap  and  brush  for 
several  minutes  under  a  jet  of  warm  water.  Of  course,  by  this 
means  we  do  not  effect  sterilization,  as  ordinary  water  contains 
germs,  but  we  make  sterilization  by  simple  measures  possible, 
for  a  similar  cleansing  with  a  brush  for  one  or  two  minutes  is 
next  effected  with  a  0.1  or  better  0.2%  acid  sublimate  solution. 
Bacteriological  examination  by  Drs.  Tavel  and  Vicquerat  has 
proved  that  the  hands,  as  a  rule,  are  rendered  sterile  by  this 


THE    TREATMENT   OP   WOUNDS.  19 

means.  If  after  such  cleansing  the  hands  are  dipped  in  gelatin 
or  we  inoculate  the  detritus  from  under  the  nails,  no  bacteria 
develop.  Of  course,  the  antecedent  occupation  is  not  without 
influence.  I  have  tested  this  on  my  own  person  in  a  case  of 
osteomyelitis  in  which  I  opened  a  large  abscess  and  purposely 
soiled  myself.  Despite  the  above-mentioned  method  of  disinfec  - 
tion,  some  colonies  of  staphylococci  developed.  After  soiling 
with  fatty  material,  washing  with  alcohol  as  recommended  by 
Fiirbringer  is  excellent. 

Under  Tavel's  direction  Dr.  Zimmermann  made  a  number  of 
experiments  by  instantaneously  infecting  small  pieces  of  meat 
with  definite  micro-organisms  and  found  that  the  sterilization  of 
such  particles  of  meat  by  placing  them  from  one  to  five  minutes 
in  0.1^  acid  sublimate  solution  is  not  always  successful,  while  it 
is  easily  effected  in  the  case  of  infected  strips  of  blotting-paper. 
Therefore  we  must  have  great  care  not  to  soil  our  hands,  and 
those  of  all  persons  taking  part  in  the  operation,  with  infectious 
materials.  By  no  means  should  we  make  a  post-mortem  ex- 
amination and  still  less  dress  infected  wounds  before  an  opera- 
tion, although  competent  surgeons  have  declared  it  to  be  ad- 
missible. 

With  hands  previously  cleansed,  both  bacteriological  exami- 
nation and  the  healing  of  the  wounds  prove  that  disinfection  can 
be  secured  by  a  thorough  scrubbing  of  the  nails,  fingers,  and 
hands  with  a  brush,  soap,  and  warm  water,  followed  by  a  final 
scrubbing  with  a  disinfected  brush  and  a  sterilized  warm  soda 
or  salt  solution,  several  times  repeated  in  fresh  liquid.  Dr.  Zim- 
mermann often  showed  that  our  hands  and  the  epidermis  scales 
from  around  and  under  the  nails  were  absolutely  free  from 
germs.  Of  course  such  washing  takes  time,  and  every  visible 
stain  must  be  thoroughly  removed  by  prolonged  brushing  under 
a  warm-water  jet.  The  brushing  and  washing  in  0.1  or  0.2^ 
sublimate  solution  increases  the  certainty  of  sterilization  and 
is   doubly   necessary  in  all  cases   where   warm   and    sterilized 


20  OPERATIVE   SURGERY. 

water  is  not  plentiful,  as  well  as  when  the  hands  have  been 
previously  soiled  directly  with  pus  or  excrement.  For  even 
if  this  does  not  kill  all  the  micro-organisms  they  are  greatly 
weakened. 

At  all  events  it  can  he  demonstrated  that  the  disinfection  of 
the  hands  and  of  the  skin  of  the  patient  is  not  as  reliable  as  the 
sterilization  and  the  preparation  of  the  instruments  and  dress- 
ings. If  we  remember  in  addition  that  accidental  infections  by 
inattention  during  an  operation  are  never  positively  excluded, 
we  shall  do  well  to  look,  upon  every  operation  wound,  no  matter 
how  carefully  made,  as  possibly  slightly  and  superficially  in- 
fected at  the  end  of  the  operation.  The  more  unfavorable  the 
conditions  the  more  certainly  do  pathogenic  germs  get  upon  the 
wound.  Hence  the  question  arises:  Can  the  wound  itself,  can 
infected  tissues  be  sterilized?  And  if  this  is  not  the  case:  How 
can  we  repair  the  damage  of  slight  superficial  and  of  grave  in- 
fection ?  As  regards  the  sterilization  of  the  wound  a  few  words 
suffice.  If  according  to  the  above-mentioned  demonstration  by 
Dr.  Zimmermann  it  is  impossible  to  destroy  positively  all  the 
germs  in  a  piece  of  meat  infected  by  a  momentary  contact  with 
micro-organisms,  even  when  it  had  been  left  for  five  minutes  in 
0.1^  sublimate  solution,  there  is  no  hope  that  it  can  be  done 
with  a  wound.  Still  Zimmermann  obtained  by  his  disinfection 
quite  an  important  difference  in  degree,  since  far  less  colonies 
developed  and  these  did  so  more  slowl}^  and  at  a  later  time,  their 
virulence  having  been  weakened.  Therefore  it  need  not  surprise 
us  to  learn  that  Lister  '  takes  this  stand  as  to  the  antisepsis  of 
the  wound  and  washes  it  with  0.2^  sublimate  solution  at  the 
end  of  the  operation.  We  have  shown ""  that  the  most  excellent 
results  are  obtained  by  proceeding  aseptically  and  using  a  0.1^ 
solution  of  sublimate  for  a  single  washing  of  the  wound. 

We  guard  against  excessive  chemical  injury  of  the  tissues 

'  Paper  read  before  the  International  Med.  Congress  at  Berlin,  August,  1890. 
^  Correspondenzblatt  f.  Schweizer  Aerzte,  Jan.  1st,  1888. 


THE   TREATMENT   OF   WOUNDS.  21 

and  overabundant  absorption  of  the  sublimate  by  a  final  thor- 
ough washing  of  the  wound  with  0.75^  sterilized  salt  solution. 

As  to  the  opening  of  the  large  cavities  of  the  body,  proof  has 
been  furnished  that  excellent  results  can  be  obtained  without 
any  antiseptic  irrigation;  but  the  condition  of  the  serous  mem- 
branes and  cavities  is  no  guide  for  other  injured  tissues  such 
as  connective  tissue  and  muscles.  With  reference  to  laparato- 
mies  we  have  likewise  restricted  ourselves  for  many  years  to  the 
antiseptic  preparations  previous  to  the  operation,  i.e.,  to  what  is 
now  generally  called  the  aseptic  treatment  of  wounds.  The 
wound  cavity  is  merely  rinsed  with  sterilized  salt  solution.  But 
numerous  experiments — for  instance,  with  the  peritoneum — 
prove  that  the  serous  membranes  are  very  tolerant  of  infectious 
materials  or  digest  them  with  relative  facility  and  render  them 
harmless,  perhaps  by  the  assistance  of  serous  transudation,  so 
long  as  the  endothelium  remains  intact  (experiments  by  Tavel 
and  Walthard) ;  but  that  the  injured  tissues  in  a  wound  are  not 
in  an  equally  favorable  state.  However,  observations  by  Lanz 
show  that  micro-organisms  develop  much  more  frequently  in 
the  clot  of  drainage  tubes  when  the  wound  runs  a  favorable 
course  than  in  the  bloody  secretions  from  the  depth  of  the 
wound.  Hence  we  may  hope  that  here  too  a  small  quantity  of 
micro-organisms,  especially  when  weakened,  are  exposed  in  the 
wound  to  similar  influences  which  delay  or  arrest  their  develop- 
ment. Upon  this  disinfectant  effect,  especially  of  the  transud- 
ing blood  serum  and  the  living  tissues,  we  may  rely  for  supple- 
menting our  aseptic  wound  treatment,  which  thus  far  does  not 
offer  absolute  security  and  in  a  concrete  case  probably  never  will. 

Our  last  but  by  no  means  worst  auxiliary  for  obtaining  the 
aseptic  healing  of  wounds  is  to  render  impossible  a  noxious  de- 
velopment of  the  few  infectious  materials  which  may  have 
reached  the  wound  in  spite  of  every  precaution.  In  this  respect 
we  must  bear  in  mind  the  following  conditions: 

Human  tissues  through  which   the  circulating   blood   and 


32  OPERATIVE    SURGERY. 

lymph  pass  form  a  poor  nutrient  for  bacteria.  But  their  devel- 
opment is  favored  by  stagnant  blood  and  stagnant  serum  in 
the  wounds.  Thence  arises  the  indication  to  prevent  the  ac- 
cumulation of  stagnant  fluids  between  the  raw  surfaces.  This 
is  effected  in  two  ways :  (1)  the  exact  coaptation  of  well-nour- 
ished wound  margins.  We  avoid  chemically  injurious  applica- 
tions (disinfection)  and  unnecessary  mechanical  influences  (trac- 
tion, bruising,  and  pressure) ;  we  secure'  good  circulation  by  the 
proper  selection  of  the  incision  and  the  position  of  the  parts ;  and 
bring  the  raw  surfaces  into  close  contact  by  suture  and  careful 
compression.  (2)  Where  perfectly  exact  coaptation  is  impossi- 
ble, the  wound  secretions  are  conducted  outward.  The  safest 
and  the  most  excellent  means  for  this  is  an  open  treatment  of 
the  wound.     But  the  healing  in  that  case  would  be  slow. 

For  this  reason  we  have  re-introduced  the  method  of  the 
secondary  suture,  and  Bergmann  has  employed  it  extensively. 
Spengler,  Nussbaum,  Helferich,  and  others  have  variously  modi- 
fied it.  It  consists  in  leaving  the  wound  open  for  twenty -four  or 
forty -eight  hours,  rarely  longer,  and  then  closing  it  by  sutures. 
This  method  unites  the  advantages  of  the  open-wound  treatment 
with  that  of  the  suture. 

An  easier  but  less  reliable  way  is  drainage  of  the  wound. 
In  conjunction  with  complete  suture  of  the  wound,  it  should 
always  be  effected  through  special  small  openings,  by  means  of 
glass  tubes  with  large  perforations,  which  had  been  immersed 
in  O.lfo  sublimate  solution.  In  twenty-four  hours,  more  rarely 
after  forty-eight  hours,  and  exceptionally  only  after  several 
days,  the  drainage  tube  will  have  carried  off  the  fluids  effused 
in  consequence  of  the  injury  and  should  then  be  removed. 
Drainage  tubes  are  allowed  to  remain  longer  only  when  it  ap- 
pears that  a  wound  has  been  gravely  infected.  Of  course,  in 
such  a  case  an  open-wound  treatment,  with  or  without  an 
eventual  secondary  suture,  is  to  be  preferred  after  the  use  of  re- 
peated disinfection. 


THE   TREATMENT   OF   WOUNDS.  23 

The  middle  course,  as  it  were,  between  the  open  treatment 
and  drainage  is  held  by  Schede's  treatment  under  the  moist 
blood  crust.  When  the  immediate  coaptation,  of  the  wound 
margins  is  impossible  it  utilizes  the  blood  effused  into  the  wound 
to  fill  the  cavity.  The  wound  is  allowed  to  fill  with  blood,  the 
edges  are  but  partially  united  by  sutures,  and  the  rest  is  covered 
with  impermeable  tissue.  Where  neither  primary  nor  secondary 
suture  is  possible  this  method  is  much  preferable  to  the  simple 
open-wound  treatment,  with  reference  to  the  duration  of  the 
healing,  by  favoring  the  cicatrizing  process. 

When  every  facility  is  at  hand  for  effecting  perfect  asepsis 
according  to  the  above  principles,  i.e.,  for  preventing  before- 
hand any  intense  and  lasting  infection  of  the  wound,  the  meas- 
ures here  indicated  will  suffice.  But  when  one  must  operate 
under  unfavorable  external  conditions,  i.e.,  when  the  ingress 
of  larger  quantities  of  micro-organisms  cannot  be  prevented,  or 
when  a  v/ound  is  exposed  to  subsequent  infection,  as  in  opera- 
tions on  the  mouth,  pharynx,  larynx,  and  rectum,  or  when 
operations  must  be  jDerformed  within  the  limits  of  foci  of  infec- 
tion, as  in  fistulse  and  ulcers,  a  single  sterilization  of  the  recent 
wound  does  not  suffice,  but  we  require  a  lasting  effect  of  anti- 
septic measures,  namely,  continuous  antisepsis. 

This  can  be  done  in  two  ways:  (1)  By  the  repeated  applica- 
tion of  the  above-enumerated  antiseptic  agents.  This  proce- 
dure presupposes  an  open  wound.  If  the  wound  is  left  open 
through  its  entire  extent,  asepsis  may  be  secured  in  a  short  time 
by  the  repeated  direct  application  to  the  raw  surfaces  of  carbolic 
acid  or  sublimate  compresses,  at  first  every  few  hours,  then  at 
longer  intervals.  But  a  corresponding  absorption  and  poison- 
ous action  of  the  drug  is  necessarily  associated  with  it,  and  this 
serious  incidental  effect  must  be  closely  watched.  Yet  as  we  do 
not  aim  at  a  single  powerful  disinfection,  but  mainly  at  arrest- 
ing the  development  of  micro-organisms,  the  desired  object  may 
be  also  attained  by  frequently  changed  warm  antiseptic  dress- 


24  OPERATIVE   SURGERY. 

ings  impregnated  with  a  mild  solution  of  carbolic  acid  (0.5 
to  1%)  and  sublimate  (0.01^  or  with  weaker  antiseptics  such  as 
thymol  {O.lfo)  and  sahcylic  acid  (0.15^).  At  first  we  use,  as  a 
rule,  gauze  slips  dipped  in  freshly  prepared  5fo  carbolic  acid  solu- 
tion, which  are  changed  every  three  hours ;  later,  moist  warm 
compresses  impregnated  with  0.15^  salicylic  acid  solution.  Far 
less  reliable  than  compresses  with  antiseptics  is  irrigation  through 
drainage  tubes  left  in  the  wound. 

(2)  The  other  way  of  securing  a  prolonged  effect  consists  in 
impregnating  the  raw  surfaces  with  substances  which  render 
the  tissues  resistant  against  the  influence  of  micro-organisms : 
with  permanent  antiseptics  in  the  more  restricted  sense.  This 
class  includes  caustics  and  iodoform.  In  the  salts  of  mercury, 
silver,  zinc,  and  bismuth  we  possess  substances  which  combine 
with  the  albumin  in  the  tissues  and  form  albuminates  which 
resist  the  decomposing  effect  of  the  bacteria — in  fact,  these  me- 
tallic substances  act  as  direct  antiseptics  upon  the  micro-organ- 
isms. For  such  purposes  we  employ  a  one-per-cent  emulsion  of 
subnitrate  of  bismuth  or  a  similar  preparation  of  zinc.  The  re- 
sults of  our  bismuth  treatment  are  among  the  best  obtained 
previous  to  the  time  of  perfected  antisepsis.  But  the  drugs 
mentioned,  bismuth  in  particular,  are  likewise  decomposed  by 
the  processes  occurring  in  the  wound,  a  sulphate  of  bismuth 
being  formed.  These  applications,  therefore,  exert  their  full 
effect  only  when  employed  before  the  decomposition  of  the 
tissues  by  the  micro-organisms  begins,  i.e.,  upon  fresh  wounds. 
When  necrosis  of  the  tissues  has  set  in  through  decomposition, 
more  powerful  antiseptics  are  required,  such  as  tincture  of 
iodine,  pure  powdered  salicylic  acid,  or  the  thermo-cautery. 

Iodoform  belongs  to  a  different  class  from  the  caustics.  By 
the  introduction  of  this  drug  Mosetig-Moorhof  has  opened  the  way 
for  a  new  form  of  wound  treatment.  Iodoform  manifests  its 
effect  only  after  the  onset  of  decomposition  processes.  The  lat- 
ter cause  the  iodoform  to  split  up  and  thus  the  ptomaines  and 


THE   SELECTION   OF   THE   DIRECTION   OF  THE   INCISION.  25 

toxalbumins  are  fixed  and  incidentally  the  further  development 
of  the  micro-organisms  is  arrested  (De  Ruyter).  Therefore  iodo- 
form has  no  place  in  the  aseptic  treatment  of  wounds.  In 
wounds  appropriate  for  the  aseptic  treatment  its  employment  is 
senseless;  on  the  contrary,  the  wound  may  be  directly  infected 
by  its  application.  But  it  is  the  most  active  of  all  drugs  for 
counteracting  beginning  and  advanced  decomposition,  and  hence 
is  to  be  used  on  wounds  where  decomposition  must  be  expected 
from  insufficient  asepsis.  De  Ruyter's  investigations  show  that 
Bergmann's  favorite  mode  of  pouring  into  the  wound  a  solution 
in  ether  and  alcohol  (iodoform,  10;  ether,  20;  alcohol,  80  parts) 
is  to  be  preferred.  Iodoform  possesses  the  drawback  that  it 
produces  marked  poisonous  effects  in  certain  persons,  especially 
on  the  central  nervous  system,  so  that  it  should  be  used  with 
great  care  and  in  accurate  doses. 

Special  mention  should  be  made  of  the  fact  that  wounds 
made  when  intense  infection  already  exists,  as  in  fistulge,  etc., 
are  to  be  united  by  sutures  only  in  exceptional  cases.  As  a  rule, 
the  open  treatment,  with  or  without  secondary  suture,  will  be 
necessary. 

D.  The  Selection  of  the  Direction  of  the  Incision. 

Before  the  period  of  anaesthesia  and  of  asepsis  in  wounds  it 
was  a  wise  plan  to  make  incisions  where  they  could  be  done 
rapidly,  where  a  small  size  sufficed,  and  where  gravity  insured 
free  egress  to  the  secretions. 

The  latter  indication  can  nowadays  be  perfectly  met  by 
separate,  very  small  incisions  for  the  introduction  of  drainage 
tubes.  On  the  other  hand  we  still  see  some  teachers,  when 
instructing  students  in  tying  arteries,  giving  directions  how 
to  find  an  artery  through  the  smallest  possible  incisions.  Such 
practice  is  no  longer  justified.  The  true  surgeon  is  recognized 
by  his  splitting  the  skin   to  an  ample  extent,  yet  proceeding 


Fig.  5. 


Fig.  2. 


Fig.  0. 


Temporal  incision  (trigeminus,  III. ) 
Nasal  incision 


Upper  neck  incision  (aditus  I 
laryngis)  f 


Axillary  incision 
(anterior  half) 


Hypochondrial  I 
incision        f 


Hypogastric  inci- 
sion (vermiform 
appendix) 


Eyebrow  incision  (trigeminus,  I.) 


Upper  maxillary  incision  (trigem.  II.) 
Cheek  incision  (operations  on  tongue) 
( Incision  for  the  upper  cervical  trian- 
.  1  gle  (external'carotid  artery) 

Lower  neck  incision  (struma) 

Incision  for  the  lower  cervical 
triangle  (subclavian 
artery) 


J  Mammary  gland 
j  incision 


Epigastric  incision 

Hypogastric    inci- 
j      sion  (common 
'     iliac  artery,  sig- 
moid flexure) 


Bladder  incision 


Knee  incision 


j   Lower  inguinal  incision 
/  (common  femoral  artery) 

Upper  inguinal  incision 

Scrotal  incision 


Fig.  7. — Normal  Incisions. 


THE   SELECTION   OF  THE   DIRECTION   OP  THE  INCISION.  29 

with  the  greatest  care  and  conservatism  in  the  depth  of  the 
wound.  A  large  cutaneous  incision  forms  no  appreciable 
additional  injury  as  compared  with  a  smaller  one,  for  an 
exact  suture  unites  it  as  quickly,  safely,  and  beautifully  as 
the  latter.  Moreover,  the  extent  of  the  cicatrix  remaining 
is  of  no  importance,  provided  it  occupies  a  suitable  direction. 
This  brings  us  to  the  point  which  we  have  adhered  to  for  years 
as  decisive  in  placing  the  incision. 

Langer's  investigations  into  the  directions  in  which  the  skin 
splits  show  that  the  tension  of  the  skin  varies  greatly  in  two 
different  directions.  Two  incisions  vertical  to  each  other  ex- 
hibit a  varying  retraction  of  the  wound  margins:  while  one 
gapes  widely,  the  edges  of  the  other  remain  in  contact  even 
without  artificial  means.  This  fact  has  to  be  borne  in  mind  in 
choosing  the  direction  of  the  incision,  unless  other  factors  have 
a  determining  effect  in  a  concrete  case ;  for  the  course  of  the 
vessels  and  especially  of  the  larger  and  smaller  nerve  twigs  is 
even  more  important  for  the  direction  of  the  incision.  Thus  in 
incisions  in  the  face  the  first  care  will  be  as  regards  the  course 
of  the  branches  of  the  facial.  Fortunately  the  course  of  the 
nerves  and  vessels  largely  coincides  with  the  direction  in  which 
the  skin  shows  the  greater  tension,  so  that  a  cutaneous  incision 
adapted  to  the  cleavage  line  corresponds  also  with  the  course  of 
the  important  nerves  and  vessels. 

For  years  we  have  noted  our  incisions  which  were  not  united 
by  suture  in  a  schematic  diagram,  according  as  to  whether  they 
appeared  open  or  closed  when  the  dressings  were  changed.  For 
this  purpose  we  made  use  of  the  drainage  openings  made  close 
to  the  sutured  cutaneous  wounds.  If  the  drainage  tubes  are 
removed  after  twenty -four  and  the  sutures  of  the  main  wound 
in  forty- eight  hours,  we  are  enabled  to  become  posted  as  to  the 
condition  of  cutaneous  wounds  not  closed  by  sutures.  We  give 
below  the  results  of  this  practice  in  juxtaposition  with  Langer's 
lines  showing  the  cleavage  lines  of  the  human  skin. 


30 


OPERATIVE  SURGERY. 


In  Figs.  2,  3,  4,  6,  and  6  the  drainage  openings  which  closed 
spontaneously  after  removal  of  the  tubes  are  represented  by  a 
single  line;  those  in  which  the  openings  remained  patulous,  by 
a  spindle-shaped  mark.  Fig.  2  shows  how  largely  well-directed 
incisions  correspond  with  Langer's  cleavage  lines,  as  might  have 
been  expected  a  priori. 

This  having  been  ascertained,  we  gradually  came  to  prefer 
the  direction  of  the  cleavage  lines  also  for  the  longer  incisions, 
and  have  convinced  ourselves  that  the  difference  in  cicatrization 

after  incisions  with  or  against  the 
cleavage  lines  is  so  important  that  it 
behooves  us  to  indicate  normal  inci- 
sions for  every  region  of  the  body. 
These  show  for  that  particular  region 
the  cleavage  lines  of  the  skin  and  at 
the  same  time  are  so  placed  as  to 
avoid  the  course  of  important  super- 
ficial nerves  and  vessels.  We  have 
convinced  ourselves  in  the  case  of  our 
frequent  operations  for  struma  that 
the  cicatrices  after  such  a  normal  in- 
cision become  so  faint  in  the  course  of 
time  that  they  are  hard  to  recognize, 
while  cicatrices  after  incisions  in  different  directions,  especially 
on  the  neck,  may  often  cause  great  deformity  by  contractions 
and  folds. 

We  therefore  have  added  diagrams  containing  our  normal 
incisions  (Figs.  Y,  8,  and  9).  Of  course,  these  refer  mainly  to 
the  large  incisions  made  on  the  head,  neck,  trunk,  and  the  ar- 
ticular regions.  For  the  remaining  incisions,  especially  in  the 
inter -articular  portions  of  the  extremities,  we  have  retained  the 
straight  longitudinal  direction  in  the  case  of  shorter  incisions 
(for  ligatures  and  the  exposure  of  nerves)  for  the  sake  of  sim- 
plicity.    One  glance  at  the  figures  shows  that  a  portion  of  these 


Auricular  incision 
(mastoid  antrum) 

Incision  for  the  upper 
cervical  triangle 

Transverse  cheek  incision 
Temporal  incision 

Superior  maxillary  incision 
Fig.  8. 


"Upper  nuchal  incision  Coccipital  I. 
nerve  and  artery;  S 

Shoulder  incision  (shoulder  / 
resection) 


Axillary  incision 
(posterior  half) 


Resection  of  ribs 

Lumbar  incision  l_ 

(nephrotomy)    f 

Elbow  incision  (re-  I 
section  of  the  elbow)  \ 


Posterior  pelvic  incision 
(rectal  resection) 


Fig.  9.— Normal  Incisions. 


32  OPERATIVE   SURGERY. 

longitudinal  incisions  likewise  coincides  with  the  cleavage  lines 
of  the  skin. 

We  need  hardly  say  that  we  include  among  the  normal  in- 
cisions all  the  longitudinal  incisions  placed  in  the  median  line  of 
the  body,  that  is  to  say,  all  the  incisions  corresponding  to  a  ver- 
tical line  from  the  vertex  to  the  symphysis,  across  the  perineum 
to  the  anus,  and  returning  behind  to  the  vertex. 

In  the  case  of  amputations,  of  course,  a  coaptation  of  seg- 
ments of  skin  naturally  belonging  together  is  out  of  the  ques- 
tion. But  even  here  it  seems  to  be  an  advantage  to  keep  to 
some  extent  to  the  cleavage  lines  of  the  skin,  so  as  to  have  less 
retraction  of  the  flaps. 

How  well  the  oblique  incisions  for  amputations  specially  rec- 
ommended by  us  fit  the  cleavage  lines  of  the  skin  is  shown  by  a 
glance  at  the  figures. 


PART  II. 

SPECIAL   OPERATIONS. 

E.     The  Skull. 
a.  Soft  Parts. 

The  soft  parts  of  the  skull  are  distinguished  by  a  profusion 
of  vessels,  but  these  are  easily  accessible  for  ligation,  as  they 
pass  through  the  scalp  whose  cutis  and  corium  are  firmly  united 
to  the  galea.  The  arteries  lie  quite  loose  in  the  scalp,  the  veins 
less  so,  and  hence  they  do  not  retract  like  the  arteries.  In  arte- 
rial hemorrhage  pressure  is  made  on  the  skin  next  to  the  edge 
of  the  wound  and  the  vessel  is  seized  with  an  artery  forceps ; 
should  this  fail  even  with  our  arterial  hook  forceps,  the  needle 
is  passed  around  it  close  to  the  wound. 

The  vessels  which  carry  the  blood  to  the  dome  of  the  head 
come  from  the  forehead,  the  temples,  and  the  occiput.  If  in 
profuse  hemorrhages  the  flow  is  to  be  arrested  from  the  centre, 
attention  should  be  directed  to  these  three  points. 

1.  Temporal  Artery  and  Vein. — Auriculo- Temporal  Nerve 
{Trigeminus  III.).  (See  Figs.  10  and  11.) — One  centimetre 
in  front  of  the  ear  the  finger  feels  at  the  upper  edge  of  the 
zygomatic  arch  the  pulsation  of  the  temporal  artery ;  in  hemor- 
rhage of  one  of  its  branches  pressure- with  one  finger  can  here 
control  it  and  it  may  be  ligated  at  the  same  point.  Incision  is 
made  in  a  vertical  direction,  one  centimetre  in  front  of  the  an- 
terior end  of  the  helix.  After  dividing  the  skin  the  fascia  ap- 
pears, namely,  the  superficial  layer  of  the  galea  aponeurotica. 
Here  the  artery  passes  over  the  zygomatic  arch  and  appears 
subfascially  at  its  upper  edge. 


34 


OPERATIVE    SURGERY. 


The  position  of  the  temporal  vein  is  not  constant ;  usually  it 
lies  parallel  with  the  artery  and  behind  it. 

Of  more  importance  is  the  nerve  here  situated  which  fur- 
nishes the  sensory  supply  to  the  ear  and  the  temporal  region, 
the  auriculo-temporal  nerve  (see  Figs.  10  and  11)  from  the  third 
branch  of  the  trigeminus.     It  encircles  the  artery  from  behind 


j  Temporal  artery 

I  Auriculo-temporal  nerve 


Superior  thyroid  artery 

Vertebral  artery ) 

Inferior  thyroid  artery  V 

CEsophagotomy ) 


(  External  and  internal  caro- 
j        tid  artery 

Hypoglossal  uerve 

Lingual  nerve 


Fig.  10. 


forward  to  above  backward  and  passes  upward  parallel  to  its 
posterior  side.  If  the  nerve  is  to  be  stretched  or  exposed  in  the 
case  of  neuralgia,  the  artery  is  located  and  the  nerve  found 
nearer  toward  the  ear.  Higher  up  the  branches  of  the  nerve 
and  the  artery  pass  into  the  scalp. 

2.  Supra- Orbital  Artery . — Supra- Orbital,  Frontal,  andEth- 
moidal  Nerves  (Figs.  12  and  13). — The  main  artery  of  the  fore- 
head is  the  supra-orbital.     It  is  smaller  than  the  temporal  artery. 


THE   SKULL. 


35 


As  guiding-point  for  its  ligation  we  have  the  paljjable  supra- 
orbital foramen ;  here  the  artery  emerges  in  a  sagittal  direction 
from  the  orbit ;  it  passes  through  the  fibres  of  the  orbicularis 
vertically  upward  under  the  galea.  After  shaving  the  eyebrow 
the  incision  is  made  transversely  at  the  supra-orbital  margin 
and  carried  deeper. 


Hypoglossal  nerve 
Occipital  artery 

Ext'nal  maxillary  artery 
Common  facial  vem 
Submaxillary  gland 

Lingual  artery- 

Scalenus  anticus  muscle 

Thyroid  gland 

Inferior  thyroid  art(  ry 

Recurrent  laryngeal  nerve 


Descending  branch  of  the 
hypoglossal 


Zygomatic  arch 


—  Temporal  artery 

Auriculo-temp"l  nerve 
Temporal  vein 


Internal  jugular  vein 
Sterno-mastoid  muscle 

\  Descending  branch  of  the 

i         hypoglossal 
Internal  carotid  artery 
External  carotid  artery 

Omo  hyoid  muscle 

-— Stemo-mastoid  muscle 

Common  carotid  artery 

Phrenic  nerve 


Longus  colli  muscle "" 

Sterno-hyoid  muscle 


Fig.  11. 


At  the  same 
orbital  neuralgia 
guiding-point  for 
through  the  skin, 
mediately  on  the 
without  injuring 
the  eyebrow  has 
the  facial.     The 


point  is  the  supra-orbital  nerve.     In  supra- 

the  supra-orbital  foramen  is  likewise  the  best 

the  incision  because  it  can  be  positively  located 

The  nerve  lies  deeper  than  the  artery,  im- 

periosteum ;  it  is  not  easy  to  sever  the  nerve 
the  artery  at  the  same  time.  The  incision  in 
the  advantage  that  it  avoids  the  branches  of 
orbicularis  and  the  frontalis  muscles  are  sup- 


36 


OPERATIVE   SURGERY. 


plied  by  the  facial ;  the  corresponding  nerve  twigs  enter  them 
from  a  lateral  direction  and  therefore  are  not  touched  by  the 
transverse  incision  recommended. 

3.  The  frontal  nerve  lies  about  two  centimetres  toward  the 
median  line  from  a  vertical  above  the  inner  canthus ;  it  is  much 
thinner  and  more  superficial  in  the  fibres  of  the  orbicularis,  ris- 


(  Supra-orbital  artery 
<  Supra-orbital  nerve 
( Frontal  nerve 


j  Frontal  sinus 
1  Ethmoidal  sinus 


( Infra-orbital  nerve 
1  Supramaxillary  nerve 


ing  almost  vertically.     In  order  to  expose  it  we  use  the  inner 
half  of  the  eyebrow  incision. 

4.  The  ethmoidal  nerve  (Fig.,  12)  passes  at  the  inner  and 
upper  circumference  of  the  orbit  into  the  cranial  cavity  and 
leaves  it  again  through  the  cribriform  bone,  spreading  over  the 
nasal  septum  and  supplying  with  its  terminal  branch  the  tip  of 
the  nose.     It  can  be  well  seen  and  ligated  with  an  aneurism 


THE   SKULL. 


37 


needle,  about  2  cm.  behind  the  median  end  of  the  supra-orbital 
margin.  The  eyebrow  incision  is  somewhat  prolonged  down- 
ward over  the  root  of  the  nose  (the  branches  of  the  angular 
artery  and  vein  being  ligated),  the  periosteum  is  divided,  and 
at  the  inner  and  upper  circumference  of  the  orbit  it  (the  peri- 


Froutal  sinus 


Frontal  nerve 

Supra-orbital  nerve 

Supra-orbital  artery 

Supra-orbital  margin 

Orbicularis  muscle 

Orbicularis  muscle — r- 

Zygoma — ^1 
Infra-orbital  nerve 
Masseter  muscle 


orbita)  is  slowly  stripped  off  backward  until  the  transversely 
stretched  cord  running  to  the  anterior  ethmoidal  foramen  is 
seen  to  separate  from  the  roof  of  the  orbit.  The  ethmoidal  ar- 
tery (from  the  naso-frontalis  artery)  is  torn  in  this  manipula- 
tion and  the  hemorrhage  is  arrested  by  tampons. 

5.   Occipital  Artery. — Major  and  Minor  Occipital  Nerves 
(Figs.  14  and   15). — The  occipital  is  the  thickest  artery  of  the 


38 


OPERATIVE    SURGERY. 


head.  Midway  between  the  occipital  spine  and  the  highest  point 
of  the  mastoid  process  the  artery  emerges  from  under  the  me- 
dian edge  of  the  splenius  muscle  and  piercing  the  fascia  it  rises 
toward  the  occiput,  where  it  lies  under  the  galea.  The  vessel  is 
ligated  at  the  point  where  it  pierces  the  thick  fascia.  The  inci- 
sion for  its  ligation  runs  transversely  in  the  line  uniting  the 


Occipital  artery ) 
Major  occipital  nerve  >■ 
Minor  occipital  nerve ) 


Major  occipital  nerve 


Fig.  14. 


abovementioned  points  along  the  semicircular  line  from  the  pos- 
terior lower  circumference  of  the  mastoid  process  to  the  level  of 
the  belly  of  the  trapezius.  The  skin  here  is  very  thick.  Divid- 
ing the  fascia,  the  posterior  edge  of  the  sterno-cleido-mastoid 
muscle  is  exposed,  avoiding  the  minor  occipital  nerve  (from 
the  third  cervical)  which  rises  to  the  occiput  along  this  edge 
(Figs.  14  and  15).     Under  the  sterno-cleido-mastoid  muscle  ap- 


THE   SKULL. 


39 


pears  the  splenius  capitis,  whose  fibres  ascend  obliquely  forward  ; 
at  its  anterior  edge  is  tbe  longissimus  capitis  muscle.  The 
splenius  is  divided  in  the  direction  of  the  cutaneous  incision ;  the 
artery  appears  beneath  it,  first  resting  on  the  obliquus  capitis 
superior,  then  on  the  semispinalis  capitis  muscle. 

The  artery  can  be  ligated  at  the  median  edge  of  the  splenius 
muscle,   where  it  rises  subfascially  in  the  angle  between  the 


Trephining  of  the ) 
transverse  sinus  ( 

Trapezius  muscle  ^ 

Major  occipital  nerve 

Occipital  artery. 

Splenius  capitis  muscle 

Minor  occipital  nerve 

Semispinalis  muscle J! 

Sterno-mastoid  muscle 
Splenius  capitis  muscle 

Trapezius  muscle 

Semispinalis  capitis  I 

muscle  j 

Trapezius  muscle 


Splenms  capitis 
—  /  muscle 

Major  occipital  nerve 
j  Obhqiuis  capitis  in- 
/      ferioi  muscle 
Splenius  capitis  muscle 


Fig.  15. 


posterior  edge  of  the  sterno-cleido-mastoid  and  the  anterior  edge 
of  the  trapezius  muscle  to  the  skin  of  the  occiput.  At  this  point 
it  is  met  by  the  major  occipital  nerve  which  comes  from  the 
median  direction. 

At  its  origin  the  occipital  artery  can  be  ligated  through 
the  same  incision  as  the  external  carotid  artery  (which  see). 
At  that  point  it  passes  under  the  digastric  and  stylo-hyoid  mus- 


40  OPERATIVE   SURGERY. 

cles.  The  occipital  vein  is  beside  the  artery,  but  its  position  is 
not  constant. 

6.  The  major  occipital  nerve  (posterior  branch  of  the  second 
cervical  (Figs.  14  and  15),  after  piercing  the  semispinalis  capitis 
muscle,  comes  to  the  surface  at  the  lateral  margin  of  the  trape- 
zius muscle.  On  ligating  the  artery  the  nerve  is  usually  found 
near  its  median  side,  the  two  approaching  each  other. 

If  a  more  central  point  of  the  nerve  is  sought  for  stretching, 
as  in  neuralgias,  the  incision  must  be  made  deeper  (Figs.  14 
and  15).  Incision  transversely  at  the  height  of  the  strongly 
projecting  spur  of  the  epistropheus,  laterally  from  the  median 
line.  The  comparatively  thin  trapezius  is  cut,  beneath  it  the 
thick  splenius  capitis  with  its  oblique  fibres  running  upward  and 
outward,  and  then  the  vertical  stout  semispinalis  are  divided, 
until  the  obliquus  capitis  inferior  muscle  appears,  which  runs 
outward  and  slightly  upward.  The  thick  nerve  is  seen  upon  it ; 
it  rises  over  the  lower  lateral  edge  of  the  muscle  and  runs  trans- 
versely medially  and  upward.  At  this  point  the  nerve,  which 
is  mainly  sensory,  contributes  some  motor  branches  to  the  nuchal 
muscles. 

The  minor  occipital  nerve  (Figs.  14  and  15),  from  the  third 
cervical  nerve.  After  reaching  the  posterior  margin  of  the 
sterno-cleido-mastoid  muscle,  it  passes  subfascially  upward  par- 
allel to  this  margin  to  the  occiput,  giving  off  branches  laterally 
from  the  field  supplied  by  the  major  occipital  nerve.  (For  its 
exposure  see  Occipital  artery.) 

h.  The  Relations  of  the  Cerebral  Convolutions  to  the  Skull. 

Since  physiological  experiments  and  complementary  experi- 
ences of  surgeons  on  the  living  patient  have  positively  demon- 
strated that  certain  cortical  regions  of  the  brain  represent  foci ' 
for  definite  functions  of  a  motor,  sensory,  and  tactile  variety, 

'  We  prefer  this  term  to  the  word  "  centres"  used  by  Horsley. 


THE   SKULL.  41 

the  surgeon  is  called  upon  to  find  strictly  circumscribed  portions 
of  the  brain  cortex  in  paralytic  and  irritative  conditions. 

Different  methods  have  been  resorted  to  in  order  to  obtain 
guiding  points  as  to  the  relations  of  the  cortex  of  the  brain  to 
the  cranium  or  to  points  on  the  surface  of  the  head  accessible  to 
palpation  and  inspection.  These  can  be  of  service  only  in  so  far 
as  they  may  be  promptly  applicable  to  different  shapes  and  sizes 
of  heads. 

The  method  of  percentage  measurements  introduced  by  Dr. 
Miiller  is  one  of  the  most  reliable  for  striking  again  and  again 
the  same  points.  It  consists  in  drav/ing  connecting  lines  from 
two  main  lines  which  are  subdivided  in  a  definite  manner.  The 
relations  of  the  points  thus  obtained  to  the  regions  of  the  brain 
lying  beneath  them  are  ascertained  from  a  larger  number  of 
observations.  Our  procedure  is  an  analogous  one :  Dr.  Schenk, 
of  Berne,  has  constructed  for  us  an  instrument  consisting  of  two 
spring  steel  strips,  which  can  be  adapted  and  applied  without 
difficulty  to  any  skull  by  means  of  an  elastic  band  running  across 
the  forehead,  occiput,  and  temples.  Being  divided  into  centi- 
metres and  millimetres,  the  various  lines  can  be  adjusted  to  a 
relative  percentage.  By  means  of  the  elastic  band  the  instru- 
ment is  placed  transversely  around  the  skull  (equatorial  lines) 
so  that  its  upper  margin  (point  A)  strikes  in  front  the  crista  gla- 
bellse  (this  is  the  name  we  propose  for  this  ridge)  which  unites 
the  arcus  superciliares  across  the  root  of  the  nose,  in  width  about 
equal  to  the  thumb;  behind  it  strikes  the  lowest  point  of  the 
occipital  protuberance  (point  B).  The  band  passes  directly  over 
the  upper  attachment  of  the  auricle.  In  a  sagittal  direction  an 
elastic  strip  runs  from  the  glabella  to  the  occipital  protuberance 
(sagittal  meridian).  On  this  meridian  a  second  elastic  strip 
bearing  a  graduated  circle  is  movable  and  can  be  fixed  at  any 
desired  point  of  the  sagittal  meridian  and  at  any  angle. 

From  the  point  midway  (Figs.  16  and  17)  between  the  crista 
glabella?  and  the  occipital  protuberance  (the  upper  pole  of  the 


42 


OPERATIVE   SURGERY. 


sagittal  meridian  =  point  C)  we  draw  two  oblique  meridians,  each 
at  an  angle  of  60°,  running  forward  and  backward  respectively 
(anterior  [line  CGHJ]  and  posterior  [line  CSTV]  oblique  meridi- 


>      IB 


Fig.  16. 


an).  A  third  line  is  more  complicated.  For  its  construction  the 
sagittal  meridian  is  divided  into  three  parts  (anterior  [point  D] 
and  posterior  [point  E]  third  point  of  the  sagittal  meridian) .  The 
posterior  half  of  the  sagittal  meridian  is  divided  into  two  equal 
parts  (posterior  fourth  point  [point  F]).     From  the  centre  (point 


THE   SKULL. 


43 


X)  between  the  posterior  fourth  point  and  the  posterior  third 
point  extends  an  oblique  line  XYZi^J,  the  movable  spring  strip 
being  applied  from  here  to  the  surface  of  the  head.  At  the  tem- 
ple it  intersects  the  equatorial  line  about  1  cm.  behind  the  oblique 


Fig.  ir. 

anterior  meridian.  The  two  oblique  meridians  and  the  oblique 
line  are  divided  into  three  equal  parts  and  thus  we  obtain  a 
sufficient  number  of  definite  points  for  localization  on  the  surface 
of  the  brain. 

We  have  demonstrated  on  a  large  number  of  brains  those 
points  of  the  cerebral  cortex  which  correspond  to  the  above-men- 


44 


OPERATIVE   SURGERY. 


tioned  points  on  the  surface  of  the  head  and  have  convinced  our- 
selves that  we  are  thus  put  in  possession  of  the  main  points  whose 
function  is  known  and  whose  location  comes  in  question  on  the 
living  patient.     Instead  of  long  explanations  we  have  had  the 


Fig.  18. 


artist  designate  the  points  determined  by  the  various  observations 
(Figs.  18  and  19)  precisely  as  we  had  marked  them,  after  per- 
foration of  the  skull  at  the  respective  points,  by  the  injection  of 
a  minute  drop  of  aniline  solution  with  a  hypodermic  syringe. 
The  following  remarks  remain  to  be  added  regarding  the 


THE   SKULL, 


45 


drawings.  The  equatorial  line  corresponds  to  the  greatest  hori- 
zontal circumference  of  the  brain;  in  front  at  A  it  coincides 
with  the  anterior  pole  of  the  frontal  brain,  behind  at  B  it  lies 
nearly  1  cm.  below  the  posterior  pole  of  the  occipital  brain,  and 
laterally  it  passes  over   the  temporal   lobe.     The  intersection 


(J)  of  the  anterior  oblique  meridian  with  the  equatorial  line 
is  situated  on  the  skull  at  the  pterion  (the  junction  of  the  fron- 
tal, sphenoidal,  temporal,  and  parietal  bones),  and  on  the  brain 
at  the  anterior  end  of  the  fissure  of  Sylvius,  where  the  horizon- 
tal ramus  of  this  sulcus  passes  into  the  anterior  ascending  one. 


46  OPERATIVE   SURGERY. 

Hence  it  designates  the  depression  between  the  frontal  and  tem- 
poral brain. 

The  intersection  of  the  posterior  oblique  meridian  with 
the  equatorial  line  (V)  marks  the  limit  between  the  temporal 
lobe  and  the  occipital  brain.  This  point  lies  1  cm.  below  the 
margin  which  divides  the  external  and  inferior  surfaces  of  the 
brain.  The  upper  pole  of  the  sagittal  meridian  (C)  lies  at 
the  highest  point  of  the  anterior  central  convolution  in  front  of 
the  fissure  of  Rolando. 

The  upper  third  point  of  the  anterior  oblique  meridian  (G) 
is  the  point  where  the  anterior  central  convolution  joins  the  first 
and  second  frontal  convolutions. 

The  lower  third  point  of  the  anterior  oblique  meridian  (H) 
marks  the  place  where  the  second  and  third  frontal  convolutions 
join  the  anterior  central  convolution. 

On  the  posterior  oblique  meridian  the  upper  third  point  (S) 
lies  over  the  interparietal  sulcus  in  the  upper  parietal  lobe,  ex- 
actly above  the  supramarginal  gyrus. 

The  lower  third  point  (T)  of  the  posterior  oblique  meridian 
marks  the  posterior  end  of  the  first  temporal  fissure  and  hence 
lies  under  the  angular-gyras. 

The  oblique  line  at  the  intersection  with  the  sagittal  me- 
ridian (X)  corresponds  about  to  the  tip  of  the  lambdoidal  su- 
ture on  the  skull  and  the  parieto-occipital  fissure  of  the  brain. 

The  upper  third  point  of  the  oblique  line  (Y)  lies  in  the  an- 
gular gyrus,  the  lower  third  point  of  the  oblique  line  (Z)  in  the 
posterior  end  of  the  horizontal  portion  of  the  fissure  of  Sylvius. 
The  intersection  of  the  oblique  line  with  the  equatorial  line  (^) 
strikes  the  anterior  end  of  the  first  temporal  fissure. 

It  is  at  once  evident  that  by  these  points  we  have  sufficiently 
marked  all  the  motor  and  sensory  centres  thus  far  known.  On 
the  skull  the  bregma  (the  point  where  the  sagittal  and  the  coronal 
sutures  join)  can  be  found  by  dividing  the  sagittal  meridian  into 
three  parts.     The  anterior  third  point  (D)  corresponds  to  it  and 


THE   SKULL.  47 

marks  the  limit  between  the  first  frontal  convolution  and  the 
anterior  parts. 

7.  Centres  of  the  Brain  Cortex. — Basing  on  Horsley's  classi- 
cal investigations  on  the  centres  in  the  cerebral  cortex  of  the 
monkey,  we  give  a  synopsis  of  the  known  centres  of  the  human 
brain  or  the  points  where  the  skull  must  be  opened  in  lesions  of 
separate  centres.  In  compliance  with  our  request  Professor 
Horsley  was  kind  enough  to  send  us  autograph  drawings  which 
we  here  reproduce  (Figs.  20  and  21) .  Comparison  with  the  draw- 
ings shows  that  the  known  centres  of  the  cerebral  cortex  are 
.  grouped  in  a  simple  manner  around  the  points  which  our  method 
of  measurement  enables  us  to  determine. 

The  crown  of  the  trephine  is  to  be  ai3plied  directly  to  the 
side  of  C  for  the  low^er  extremity,  or  close  to  the  middle  line  for 
its  peripheral  parts  (hallux),  and  farther  away,  behind  G,  for 
its  central  portions  (hip) .  According  to  the  localizations  drawn 
from  certain  monkey  brains,  the  focus  for  the  hip  would  lie  half 
a  trephine  opening  farther  forward,  and  the  same  distance  far- 
ther backward  for  the  toes,  especially  the  great  toe. 

The  centres  for  the  upper  extremity  are  found  by  applying 
the  trephine  immediately  behind  G  as  far  as  H,  at  the  upper 
portion  for  the  shoulder  and  elbow,  at  the  lower  portion  for  the 
wrist,  fingers,  and  thumb.  According  to  other  experiments, 
the  opening  for  both  fingers  and  thumb  should  be  made  half  a 
trephine  circle  farther  back. 

Slightly  downward  behind  the  line  GH,  somewhat  above  the 
latter  point  and  over  the  entire  breadth  of  the  two  central  con- 
volutions, the  trephine  opening  strikes  the  focus  for  the  ocular 
portion  of  the  facial,  that  is  to  say,  for  the  contralateral  clos- 
ure of  the  lid.  Behind  the  line  HJ  in  the  upper  third  lies  the 
focus  for  the  contralateral  lifting  of  the  angle  of  the  mouth ;  in 
the  middle  third  that  for  retraction  of  the  angle  of  the  mouth, 
and  finally  in  the  lower  third  above  and  behind  J  the  centres  for 
the  larynx  and  pharynx,  those  for  deglutition  and  mastication 


48 


OPERATIVE   SURGERY. 


and  the  opening  of  the  mouth  in  an  oblique  backward  and  up- 
ward direction,  the  latter  centre  lying  vertically  a  good  finger's 
bread  above  ^. 

Up  and  down  before  H  lies  the  focus  for  moving  the  head 
(as  well  as  the  eyes,  according  to  our  own  clinical  observations) 
to  the  opposite  side.  In  front  of  the  middle  of  the  line  HJ  lies 
the  point  whose  lesion  is  followed  by  motor  aphasia  (Horsley 
has  failed  to  mark  this  point) ,     Below  the  posterior  half  of  the 


Fig.  20  A.  - 


line  Zi2  lies  the  focus  for  auditory  aphasia;  below  the  point  T 
that  for  visual  aphasia,  and  above  BV  the  point  for  psychical 
vision  or  psychical  blindness. 

Exposure  and  possibly  excision  might  also  be  effected  for  the 
centres  lying  immediately  adjoining  the  median  line  on  the  me- 
dian surface  of  the  brain — those  for  the  trunk  muscles  behind 
the  point  D  or  in  the  anterior  half  of  the  line  CD ;  the  centre  for 
central  vision  (or  hemianopsia)  in  front  of  the  upper  half  of  the 
line  XB. 

Finally  let  us  indicate  the  point  where  in  our  opinion  punc- 
ture of  the  lateral  ventricles  of  the  brain  can  be  performed  in 


THE   SKULL. 


49 


the  most  certain  and  least  harmful  manner.  This  may  be  done 
from  above,  from  in  front,  and  from  the  side.  From  the  pos- 
terior half  of  the  first  temporal  fissure  we  need  only  perforate  1 


I'IG.  ~M. 


cm.  of  brain  substance  (counting  from  the  depth  of  the  fissure) 
in  order  to  reach  the  posterior  horn.  In  one  of  our  cases  of  tu- 
bercular meningitis  in  which  the  trephine  was  aj^plied  behind  and 

above  the  ear,  in  front  of  the  posterior  end  of  the  crista  temporalis 

4 


50  OPERATIVE   SURGERY. 

(see  Fig.  23),  the  point  below  Z  was  exposed,  and  the  lateral 
ventricle  opened  exactly  at  the  bottom  behind  the  posterior  end 
of  the  caudate  nucleus.  But  despite  the  exact  location,  after 
one  thorough  evacuation  drainage  failed — a  fact  we  explained 
by  collapse  of  the  walls  of  the  ventricles  after  evacuation,  owing 
to  the  pressure  of  the  brain  substance  from  above. 

In  another  analogous  case  direct  drainage  from  above  suc- 
ceeded well  and  had  a  very  good  effect.  Hence  it  is  preferable 
to  reach  the  ventricle  from  above  rather  than  from  below,  al- 
though four  or  five  centimetres  of  brain  substance  must  be  per- 
forated. However,  as  puncture  directly  from  above  injures  the 
centres  for  the  lower  extremity,  it  would  be  better  to  effect  the 
object  from  without  the  motor  region,  namely,  from  above  for- 
ward, laterally  from  the  point  D  and  forward  of  the  point  Gr. 
If  puncture  is  made  here,  about  2^  to  3  cm.  from  the  median 
line  and  3  cm.  forward  of  the  precentral  fissure,  preferably  in 
the  fissure  between  the  upper  and  middle  frontal  convolution, 
as  shown  in  the  figure,  the  ventricle  is  easily  reached  backward 
and  downward,  without  the  risk  of  a  grave  lesion  of  the  cortex. 
At  present  we  have  under  treatment  a  case  of  tumor  of  the 
brain,  in  which  a  drainage  tube  introduced  in  this  manner  car- 
ries off  an  ample  amount  of  cerebro-spinal  fluid.  For  this  opera- 
tion the  crown  of  the  trephine  should  measure  at  least  4  cm. 
in  diameter,  since  according  to  Horsley  the  opening  must  be 
rather  large. 

8.  As  a  guide  we  first  make  a  puncture  with  a  hypodermic 
syringe  whose  needle  should  be  at  least  6  cm.  long ;  the  dura  is 
divided  very  slightly  so  that  the  drainage  tube  may  be  held 
rather  firmly  in  the  opening,  and  then  we  introduce  one  of  our 
arterial  hook  forceps,  by  the  opening  of  which  we  make  room 
for  the  passage  of  the  tube.  As  in  all  our  cases,  we  employ  a 
glass  drainage  tube,  6  cm.  in  length,  which  passes  through  a 
special  small  cutaneous  opening,  so  that  the  main  wound  can 
be  sutured  throughout  its  entire  extent  and  in  order  that  the 


THE   SKULL.  51 

opening  in  the  skin  may  aid  in  keeping  the  tube  in  a  definite 
direction.  The  escajDing  cerebro-spinal  fluid  is  at  first  bloody 
but  soon  becomes  quite  clear,  and  as  it  often  is  abundant  the 
dressings  should  be  frequently  changed  early  after  the  operation. 

c.   Trephining. 

Having  become  posted  as  to  the  manner  in  which  after  in- 
cisions of  the  skull  the  right  points  can  be  found  in  the  depth, 
and  how  and  where  certain  nerves  and  vessels  may  be  avoided 
or  the  latter  ligated  after  injury,  the  incision  for  trephining 
should  be  made  as  a  rule  in  the  meridian,  i.e.,  rising  vertically 
toward  the  vertex,  because  both  nerves  and  arteries  run  from 
below  upward.  When  a  longitudinal  incision  does  not  suffice 
a  flap  is  formed  with  the  base  below  and  a  broad  point  above. 
The  cross  cut  which  is  largely  used  does  great  damage.  The 
incisions  are  made  with  a  resection  knife  and  carried  vigorously 
down  to  the  bone,  the  periosteum  is  divided  and  folded  back 
with  the  flap,  which  is  easily  effected  by  the  aid  of  an  elevator ; 
only  at  the  sutures  the  periosteum  adheres  so  flrmly  that  it  must 
l3e  loosened  with  the  knife.  The  bone  is  divided  with  the  crown 
of  the  trephine,  of  the  hand  or  bow  pattern,  or  in  recent  times 
with  small  circular  saws.  Instead  of  the  trephine  the  use  of  a 
sharp  chisel  and  a  hammer  would  be  simpler,  provided  there  is 
no  ground  for  fearing  the  concussion  connected  with  it.  The 
chisel  marks  out  the  limit  of  the  opening  and  the  piece  of  bone 
thus  loosened  is  lifted  out  with  the  elevator  as  soon  as  it  proves 
movable;  the  edges  are  smoothed  with  Liiers'  paring  forceps. 
Particular  care  should  be  taken  not  to  injure  the  superficial 
dural  vessels. 

Wagner's  temporary  resection  of  the  skull  with  an  omega- 
incision  and  chiselling  out  of  the  bone  in  connection  with  the 
soft  parts  for  subsequent  replacement  appears  indicated  when 
very  large   openings  are   made   and  in  diagnostic  trephining. 


52 


OPERATIVE    SURGERY. 


The  attempt  to  lift  out  the  entire  plate  of  bone  with  the  loosely 
adhering  periosteum  does  not  always  succeed. 

9 ,  Trephining  of  the  Longitudinal  and  Transverse  Sinuses.  — 
Trephining  over  the  sinuses  of  the  dura  mater  is  done  only  when 
this  is  the  part  to  be  exposed  or  opened. 


Total  resection  of 
the  upper  maxilla 


Incision  into  the  mu- 
cous membrane  for 
the  mental  nerve 

Transverse  incision  of 
the  cheek 


Inferior  lateral  pharyngotomy 


Orbital  nerve 
Auricular  incis'n 
Mastoid  antrum 
Lateral  ventricle 
Transverse  sinus 


Trephining  of  the 
cerebellum 


Facial  nerve 
Buccinator  nerve 


Fig.  22. 


The  superior  longitudinal  sinus  lies  to  the  right  of  the  sagit- 
tal median  line. 

A  much  more  important  point  is  that  of  the 

10.  Transverse  Sinus  (see  Figs.  22  and  23). — Here  thrombo- 
sis and  suppuration  from  extension  of  inflammations  from  the 
middle  ear  are  of  the  most  frequent  occurrence.  To  locate  the 
spot  for  trephining  search  is  made  for  the  most  prominent  point 
at  the  base  of  the  mastoid  process  which  appears  posterior  to 
the  edge  of  the  auricle.     A  finger's  breadth  higher  lies  the  tem- 


THE   SKULL. 


53 


poral  ridge  which  rises  obliquely  backward.  Between  this  ridge 
and  the  former  eminence  on  the  inner  side  lies  the  transverse 
sinus  which  can  be  followed  downward  for  some  distance  along 
the  mastoid  process.  The  incision  is  made  along  the  posterior 
edge  of  the  auricle  (auricular  incision,  Fig.  22)  and  the  posterior 


Temporal  ridge 

(  Trephine   opening  for  puncture  of 
<     the  lateral  ventricle  and  for  otitic 
I     cerebral  abscess 
/  Trephin'g  of  the  mastoid  antrum 
'    '  Spina  supra  meatum 


I  Trephining  of  the  transverse 
I  sinus 


Trephining  of  the  cerebellum 


Resection  of  the 
lower  maxilla 


Fig.  23. 


margin  of  the  wound  is  drawn  slightly  backward.  After  chisel- 
ling through  the  skull  the  wall  of  the  sinus  is  exposed.  More 
frequently  we  are  called  upon  to  avoid  the  sinus  in  operations  at 
this  point,  especially  in  opening  the  mastoid  cells  (which  see). 

1 1 .  Trephining  for  Ligature  of  th  e  Middle  Meningeal  Artery 
(see  Figs.  24  and  25). — The  middle  meningeal  artery  supplies 
the  cerebral  meninges  with  blood.  For  ligating  it  a  point  is 
usually  selected  (Vogt)  two  fingers'  breadth  above  the  zygo- 
matic arch  and  a  thumb's  breadth  behind  the  zygomatic  process 


54 


OPERATIVE   SURGERY. 


of  the  frontal  bone.  But  this  point  strikes  only  a  part  of  the 
artery, '  namely,  its  anterior  branch.  If  the  posterior  branch  is 
to  be  found  at  the  same  time,  the  trephine  opening  must  be 
made  immediately  over  the  middle  of  the  zygomatic  arch  (below 
our  points  i2  and  I) .     At  this  point,  however,  not  only  must  the 


Lateral 
pharyngotomy  ( 


Lingual  artei-..- 

Hypoglossal  nerve 

Superior  laryng'l  nerve 

Common  carotid 


["Temporal  incision 
Third  branch  of  trigeminus 
-j     nerve 

I  Middle  meningeal  artery 
[  Internal  maxillary  artery 


I  Accessory  nerve 
J  Auricularis  magnus  nerve 
J  Internal  jugular  vein 
(  External  jugular  vein 


Masseter  muscle 
External  maxillary  artery 
External  maxillary  vein 

— Supraclavicular  nerves 
Trapezius  muscle 


Platysma 


Scalenus  medius 
muscle 


Stemo-mastoid  muscle 
External  jugular  vein 


Transversa  colli  artery 
Brachial  plexus 
Transverse  scapular  artery 
Subclavian  artery 
Subclavian  vein 
Scalenus  anticus  muscle 


Fig.  24. 


scalp  and  periosteum  be  divided,  but  the  temporal  muscle  with 
its  vertical  fibres  must  be  taken  into  account.  But  as  an  in- 
cision at  this  point  must  not  extend  below  the  zygomatic  arch, 
owing  to  the  branches  of  the  facial  nerve,  a  longitudinal  divi- 
sion is  not  admissible,  and  our  temporal  incision  must  be  used 
(see  Fig.   25).     This  runs  obliquely  from  the  junction  of  the 


'  See  Merkel's  Anatomy,  p.  65. 


THE   SKULL. 


55 


frontal  bone  and  the  zygoma  '  to  the  posterior  end  of  the  zygo- 
matic arch,  thence  backward  and  upward ;  it  divides  the  skin  and 
the  tense  temporal  fascia,  and  after  ligature  of  the  superficial 
temporal  artery  at  the  posterior  edge  of  the  temporal  muscle 
strikes  the  bone  from  which  the  muscle  and  periosteum  are 
turned  forward.     In  this  way  we  avoid  hemorrhage  from  the 


Sutomaxill'ry  gland 
Lingual  artery 

Hyoglossus  muscle 

Superior  laryngeal  nerve 

Common  cai  otid  artery 

Platysma  — 
Omohyoid  muscle 


Temporal  fascia 

Temporal  muscle 
Temporal  artery 

Zygomatic  arch 

Masseter  muscle 


Digastric  muscle 

Auricularis  magnus  nerve 
External  jugular  vein 
Sterno-mastoid  muscle 
Accessory  nerve 
Internal  jugular  vein 
Common  facial  vein 
Hyoglossal  nerve 
Major  cornu  of  the  hyoid  bone 

3  Descending  branch  of  the 
—   1        hypoglossal  nerve 
Vagus  nerve 

Common  jugular  vein 
Sterno-mastoid  muscle 


deeper  temporal  vessels  and  most  certainly  strike  the  spot  on  the 
squamous  portion  of  the  temporal  bone  under  which  the  artery 
lies.     The  bone  here  is  very  thin. 

There  are  two  more  points  on  the  skull  which  we  may  either 
avoid  in  trephining  or  oftener  purposely  expose,   namely,  the 


^  In  Fig.  25  the  anterior  incision  is  drawn  somewhat  too  low  in  its  anterior 


half. 


56 


OPERATIVE   SURGERY. 


frontal  sinus  and  the  antrum  with  the  mastoid  cells.  Accumu- 
lations of  pus  in  these  cavities  form  the  most  frequent  indica- 
tions for  their  opening. 

12.  Trephining  of  the  Frontal  Sinus  (Figs.  26  and  27). — • 
After  shaving,  the  incision  is  carried  in  a  curve  through  the 
eyebrow  down  to  the  bone  as  far  as  the  median  line.     The  upper 


( Supra-orbital  artery 
■<  Supra-orbital  nerve 
( Frontal  nerve 


j  Frontal  sinus 
( Ethmoidal  sinus 


( Infra -orbital  nerve 
( Supramaxillary  nerve 


Fig.  26. 

edge  of  the  wound  together  with  the  detached  periosteum  is 
vigorously  drawn  upward.  The  incision  divides  the  frontal  and 
supra-orbital  nerves  and  the  artery  of  the  same  name ;  but,  what 
is  much  more  important,  it  avoids  the  branches  of  the  facial 
extending  to  the  frontal  muscles,  the  corrugator,  and  the  orbic- 
ularis. Earely  an  additional  vertical  incision  is  required ;  this 
is  carried  obliquely  upward  alongside  the  median  line.     At  the 


THE   SKULL. 


57 


inner  end  of  the  superciliary  arch,  after  hfting  the  flap  of  skin 
and  periosteum  with  tlie  elevator,  the  sinus  is  opened  with  the 
chisel.  The  anterior  wall  contains  diploe ;  hence  some  hemor- 
rhage should  be  expected  from  its  abundant  vessels.  The  pos- 
terior wall  is  formed  by  the  vitreous  layer  alone.     Under  the  an- 


Frontal  sinus 


Frontal  nerve 

Supra-orbital  nerve 

Supra-orbital  artery 

Supra-orbital  margin 

Orbicularis  muscle 

Orbicularis  muscle  •y,'"i^ 
Zygoma  — qfr 
Infra-orbital  nerve 
Masseter  muscle 


Fig.  ir. 


terior  bony  wall  is  the  thin  mucous  membrane,  w^hich  may  be 
much  thickened  in  the  case  of  suppuration.  After  it  is  de- 
tached a  probe  can  be  carried  backward  and  downward  from  the 
sinus  into  the  nasal  cavity  beneath  the  anterior  end  of  the  mid- 
dle turbinated  bone,  and  after  forcible  dilatation  v/ithout  cutting, 
a  permanent  drainage  tube  may  be  carried  to  the  same  point. 
13.    Trephininfj  of  the  Mastoid  Process  (Figs.  28  and  20). — 


58 


OPERATIVE   SURGERY. 


The  surgeon  is  frequently  called  upon  to  open  the  hony  cavities 
of  the  mastoid  process. 

As  the  drum  cavity  communicates  with  the  mastoid  antrum 
and  the  mastoid  cells,  infectious  materials  are  apt  to  be  carried 
there ;  stagnation  favors  their  development,  they  attack  the  thin 


Total  resection  of  I 
■  the  upper  maxilla  ) 


Incision  into  the  mu- 1 
cous  membrane  for  V 
the  mental  nerve       ) 

Transverse  incision  of 
the  cheek 


Inferior  lateral  pharyngotomy 


Fig.  28. 


Orbital  nerve 
Auricular  incis'n 
Mastoid  antrum 
Lateral  ventricle 
Transverse  sinus 


J  Trephining  of  the 
1       cerebellum 


Facial  nerve 
Buccinator  nerve 


bony  walls,  and  extend  to  the  exernal  and  internal  periosteum. 
Starting  from  the  external  periosteum  a  phlegmon  forms  behind 
the  auricle.  The  internal  periosteum  is  the  dura  mater  and 
periostitis  here  is  identical  with  pachymeningitis.  This  leads  to 
the  formation  of  cerebral  abscesses  in  the  temporal  lobe  or  the 
cerebellum,  to  basilar  meningitis,  or  to  phlebitis  of  the  trans- 
verse sinus,  according  to  the  point  where  the  otitis  passed  into 
mastoid  osteitis. 

In  opening  the  mastoid  process  we  aim  first  at  the  mastoid 


THE   SKULL. 


59 


antrum  as  the  cavity  which  is  earliest  involved  from  the  drum 
cavity  in  accordance  with  the  direct  communication.  While 
egress  may  be  given  to  pus  from  the  drum  cavity  by  an  in- 
cision into  the  membrana  tympani,  an  artificial  passage  outward 
must  be  made  for  the  mastoid  antrum,  whose  anterior  opening 


Temporal  ridpo 


(Trephine  openin;?  for  puncture  of 
<  the  lateral  ventricle  and  for  otitic 
(     cerebral  aliscess 

Trephin'e:  of  the  mastoid  antrum 

Spina  supra  nieatuni 


Trephining  of  the  transverse 
sinus 


Trephining  of  the  cerebellum 


Eesection  of  the 
lower  maxilla 


Fig.  23. 


lies  higher  than  the  base  of  the  cavity.  This  is  still  more  nec- 
essary for  the  more  deeply  situated  mastoid  cells. 

In  exposing  the  cavities  of  the  mastoid  process,  any  unnec- 
essary opening  of  the  skull  cavity  is  to  be  avoided,  especially 
lesion  of  the  transverse  sinus  and  the  facial  canal  or  nerve. 

In  order  to  reach  the  mastoid  antrum  surely  by  the  most 
direct  road  without  incidental  injuries  it  is  necessary  to  expose 
the  entire  process  by  a  large  incision.  The  latter  is  made  par- 
allel to  the  posterior  margin  of  the  auricle,  the  jDeribsteum  is 


60  OPERATIVE   SURGERY. 

pushed  away  as  far  as  needed  forward  and  backward,  so  as  to 
expose  the  bony  process.  The  spina  supra  meatum  behind  and 
above  the  bony  auditory  meatus  serves  as  a  guiding-point  for 
the  application  of  the  chisel  which  niust  penetrate  vertically, 
i.e.,  in  a  median  direction.  At  a  depth  of  about  li  cm.  the 
mastoid  antrum  is  opened.  Downward  and  somewhat  back- 
ward of  this  we  strike  the  mastoid  cells  by  chiselling  away  the 
superficial  layers  of  bone  as  far  as  the  point  of  the  process.  In 
this  way  all  the  mastoid  cells  can  be  exposed.  By  deviating 
forward  from  the  direction  indicated,  or  by  penetrating  deeper 
into  the  bony  auditory  canal,  we  strike  the  facial  canal.  By 
deviating  backward  we  strike  the  transverse  sinus,  and  higher 
up  we  open  the  cavity  of  the  skull  (Figs.  28  and  29),  and  above 
the  base  of  the  pyramid  of  the  petrous  bone  we  come  to  the  pos- 
terior part  of  the  temporal  lobe  of  the  brain  through  which  the 
lateral  ventricle  may  be  opened  at  its  lowest  point.  When 
suppuration  has  extended  in  any  of  these  three  directions  this 
course  is  purposely  followed. 

14.  Trephining  of  the  Cerebellum  (Fig.  29). — This  is  per- 
formed below  the  superior  linea  nuchse  behind  the  mastoid  pro- 
cess, by  means  of  a  transverse  incision  down  to  the  bone  along 
that  line.  The  muscles  here  attached  (posterior  end  of  the 
sterno-cleido-mastoid,  splenius,  longus  capitis)  are  turned  down 
with  the  periosteum,  and  the  crown  of  the  trephine  is  applied 
back  of  the  mastoid  process.  The  minor  occipital  nerve  is  di- 
vided, the  major  occipital  nerve  and  the  occipital  artery  are 
lifted  and  turned  down  with  the  soft  parts. 

F.  The  Face. 

The  condition  of  the  skin  of  the  face  differs  from  that  of  the 
skull  in  being  looser,  but  it  is  likewise  exceedingly  vascular. 
Hence  we  must  be  prepared  for  spurting  arteries  even  in  the 
cutaneous  incision.     Most  of  the  vessels  lie  beneath  the  cutis. 

As  to  the  direction  of  the  incisions  the  same  rules  apply  as 


THE   FACE.  61 

were  given  for  placing  normal  incisions  in  general.  The  first 
care  in  operations  on  the  face  should  be  to  avoid  the  facial  nerve ; 
incisions  must  be  chosen  which  run  parallel  to  the  branches  of 
this  nerve,  for  every  injury  to  it  means  deformity. 

It  matters  very  much  less  when  an  arterial  twig  is  severed 
than  when  ever  so  small  a  nerve  is  cut.  Accordingly  the  in- 
cisions will  be  so  placed  as  to  radiate  from  the  point  of  entry  of 
the  facial  nerve  into  the  parotid  as  a  centre.  In  this  w^ay  we 
guard  against  disturbances  of  facial  expression.  Of  course  a 
portion  of  the  vessels  will  thus  be  cut  across.  On  the  other  hand 
the  normal  incisions  coincide  with  the  direction  of  Steno's  duct 
to  w^hich  they  are  parallel.  The  muscles  must  be  divided  in 
part.  In  general,  however,  division  of  muscles  is  avoided  and 
the  direction  of  their  interstices  is  j)referred,  because  wounds  of 
muscles  heal  badly  after  infection.  The  latter  factor  no  longer 
enters  into  the  question  under  asepsis;  with  it  we  may  obtain 
a  rapid  cicatrization  of  the  muscle  with  complete  restoration  of 
its  function,  provided  the  afferent  nerve  twigs  have  been  left 
intact. 

In  our  operative  surgery  we  always  come  back  to  this  point : 
rather  divide  even  a  strong  muscle  (as  for  instance  the  rectus 
abdominis)  and  produce  an  artificial  inscriptio  tendinea  than 
injure  the  afferent  nerves,  and  thus  cause  paralysis  and  atrophy 
of  the  muscle.  The  chief  artery  of  the  face  is  the  external 
maxillary, 

15.  Ligature  of  the  External  Maxillary  Artery. — The  point 
of  ligature  of  this  artery  can  be  exactly  determined :  it  passes 
up  over  the  edge  of  the  jaw,  precisely  at  the  anterior  margin  of 
the  masseter  muscle,  accompanied  by  the  anterior  facial  vein, 
whose  course  is  not  quite  constant.  An  incision  is  made  through 
the  skin  and  platysma  at  the  anterior  edge  of  the  masseter, 
parallel  to  the  margin  of  the  maxilla,  and  the  artery  is  dissected 
out  with  careful  avoidance  of  the  marginal  branch  of  the  facial 
nerve  which  passes  along  the  border  of  the  maxilla. 


62  .  OPERATIVE   SURGERY. 

16.  Operations  on  the  Nose  and  the  Nasal  Cavities. — Pene- 
tration into  the  nasal  cavities  through  the  nostrils  finds  no  ap- 
plication in  serious  nasal  affections  such  as  the  deep  inflamma- 
tions or  malignant  neoplasms.  In  such  diseases  the  interior  of 
the  nose  must  be  made  directly  accessible  to  palpation  and  in- 
spection. 

A  simple  method  for  this  purpose  is  furnished  by  the  split- 
ting of  the  nasal  septum  recommended  by  us.  The  blades  of  a 
strong  pair  of  scissors  are  passed  into  both  nostrils  as  far  as  pos- 
sible and  the  cartilaginous  septum  is  divided;  this  causes  the 
small  arteries  of  the  septum  to  spurt.  Then  the  finger  can  be 
easily  introduced  into  the  nose  and  the  walls  palpated.  In 
ozgena  this  manipulation  suffices  to  render  further  procedures 
clear,  especially  to  find  circumscribed  disease  of  the  bones  and  to 
remove  affected  pieces  of  bone.  Two  sutures  suffice  to  effect  so 
exact  a  coaptation  that  no  sign  of  the  operation  remains. 

17.  But  if  a  view  into  the  nose  is  desired  further  access 
must  be  gained.  This  is  obtained  by  a  division  of  the  nose  by 
means  of  a  median  section  (see  Nasal  incision,  Fig.  7).  But  the 
division  should  not  be  made  exactly  in  the  middle,  because  the 
nasal  cartilage  shows  a  depression  at  its  most  prominent  part 
and  the  cicatricial  retraction  after  exact  median  division  marks 
the  above-named  depression  externally,  thus  leading  to  no  in- 
considerable deformity.  Therefore  the  cartilage  and  nasal  bones 
are  divided  slightly  to  one  side  of  the  median  line,  thus  securing 
a  cicatrix  which  later  is  hardly  visible.  When,  after  the  ante- 
rior division,  the  frontal  process  of  the  upper  maxilla  and  the 
base  of  the  nasal  bone  are  chiselled  through  past  the  lachrymal 
sac  and  upward  from  the  pyriform  aperture,  one-half  of  the 
nose  can  be  turned  over  and  a  good  view  is  obtained  throughout 
the  entire  cavity  in  question. 

Another  method  is  the  lateral  division  of  the  nose  (see  Fig. 
28).  When  the  disease  is  situated  laterally  and  extends  to  the 
upper  maxilla,  the  incision  is  carried  only  around  the  ala  nasi 


THE   FACE.  G3 

and  upward  in  its  groove,  either  merely  along  the  osseous  pyri- 
form  aperture,  when  the  loosened  half  of  the  nose  is  turned  over 
toward  the  centre,  or  the  incision  is  carried,  higher,  the  chisel 
being  used  to  split  the  frontal  process  of  the  maxilla  upward  and 
the  nasal  bones  transversely.  This  procedure  gives  free  access 
to  the  anterior  portion  of  the  nose.  By  this  means  tubercular 
ulcerations  may  be  subjected  to  a  very  exact  local  treatment. 
Of  course,  the  method  has  the  disadvantage  that  it  destroys  the 
function  of  some  muscular  fibres,  namely,  the  nasal  muscle 
which  springs  from  the  alveolar  margin  of  the  upper  maxilla 
and  goes  to  the  dorsum  and  ala  nasi,  and  the  levator  alse  nasi. 
Yet  as  the  divided  muscles  may  be  made  to  heal  by  first  inten- 
tion and  the  afferent  nerve  fibres  remain  partly  intact,  no  mate- 
rial disturbance  of  the  expression  results.  When  correctly  su- 
tured, the  cicatrix  becomes  in  a  short  time  invisible.  Of  the 
vessels,  the  alar  branches  of  the  angular  artery  are  divided ;  the 
latter  artery  is  to  be  preserved  in  the  upper  portion  of  the  in- 
cision. If  a  deeper  view  into  the  nasal  passages  is  desired  than 
can  be  gained  by  the  above  method,  a  partial  osteoplastic  resec- 
tion of  the  upper  maxilla  may  be  made  (see  Fig.  28),  and  the 
inner,  anterior,  and  a  portion  of  the  upper  wall  of  the  maxillary 
sinus  turned  outward,  when  inspection  can  be  carried  to  the 
choanse.  Further  details  will  be  found  among  the  methods  of 
resection  of  the  upper  maxilla. 

Another  way  of  obtaining  free  access  to  the  posterior  portion 
of  the  nasal  cavity  consists  in  division  of  the  hard  and  soft  jDal- 
ate  by  a  median  incision.  The  mucous  and  periosteal  tissues 
are  detached  toward  both  sides  and  the  horizontal  plate  of  the 
l^alate  with  a  portion  of  the  vomer  is  chiselled  out  (Gussen- 
bauer).  By  this  means  we  expose  the  most  posterior  part  of  the 
nasal  cavity  as  far  as  the  upper  pharynx,  and  tumors  of  the 
base  of  the  skull  (fibromas  and  fibro-sarcomas)  can  be  removed 
under  thorough  control.  In  a  case  recently  operated  on  for  re- 
lapsing sarcoma  of  the  base  of  the  skull  and  the  posterior  roof  of 


64  OPERATIVE   SURGERY. 

the  nose,  we  gained  a  very  full  view  of  the  field  of  operation  by 
splitting  of  the  upper  lip,  transverse  separation  of  both  alveolar 
processes  from  the  upper  jaw,  and  median  division  of  the  hard 
and  soft  palate,  while  the  subsequent  disfigurement  was  trifling. ' 

18.  For  opening  the  cavities  of  the  sphenoid  bone  the  above- 
mentioned  method  of  Gussenbauer  is  the  most  appropriate.  The 
sphenoid  cavities  open  into  those  of  the  nose  at  the  posterior 
margin  of  the  upper  turbinated  bodies.  They  can  be  opened  at 
the  upper  circumference  of  the  choana  between  the  posterior 
margin  of  the  middle  turbinated  body  and  the  ala  of  the  vomer, 
by  perforating  the  roof  of  the  nose  with  a  narrow  sharp  spoon. 

Through  the  opened  nasal  cavity,  under  the  anterior  end  of 
the  lower  turbinated  body,  1^  cm.  behind  the  margin  of  the 
pyriform  aperture,  we  reach  the  naso-lachrymal  canal  beneath 
the  middle  turbinated  body;  2|-  cm.  behind  the  same  margin  in 
a  lateral  direction  we  strike  the  antrum  of  Highmore;  above 
this  opening,  beneath  the  same  turbinated  body,  a  probe  can  be 
carried  into  the  efferent  duct  of  the  frontal  sinus.  The  direction 
of  this  latter  canal,  as  well  as  that  of  the  nasal  duct,  is  about 
parallel  to  the  lateral  margin  of  the  pyriform  aperture. 

Another  operation  for  exposing  the  nasal  cavities  without 
injuring  the  facial  nerve  is  an  incision  from  the  sublabial  mu- 
cous membrane.  Without  touching  the  face,  the  mucous  mem- 
brane is  detached  at  the  junction  of  the  gums  with  the  upper 
lip,  the  attachment  of  the  cartilaginous  nose  to  the  pyriform 
aperture  is  divided,  and  the  whole  of  the  soft  parts  (nose  and 
cheek)  is  turned  up  to  the  eyes  (Rouge) ;  if  the  septum  is  di- 
vided in  addition,  the  entire  nasal  cavity  is  accessible  from  in 
front.  This  operation  has  the  advantage  of  leaving  absolutely 
no  deformity,  but  it  causes  profuse  hemorrhage. 

19.  Free  Exposure  of  the  Antrum  of  Highmore  {Maxillary 
Sinus). — One  method  of  reaching  the  antrum  we  have  learned 

^  Dr.  Lanz  will  furnish  a  more  minute  description  of  this  method  of  opera- 
tion. 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE.  65 

in  connection  with  exposure  of  the  nasal  cavity.  Even  when 
ample  exposure  is  desired  it  is  customary  to  avoid  an  external 
incision  and  to  proceed  through  the  mucous  membrane,  either 
from  the  mouth  or  from  the  nose.  The  antrum  frequently  con- 
tains jjurulent  foci  after  prolonged  inflammations,  and  therefore 
we  are  often  called  ujDon  to  open  the  maxillary  sinus  perma- 
nently. The  point  from  which  access  is  most  readily  gained  for 
the  purpose  of  free  exposure  and  careful  examination  is  the 
canine  fossa.  We  lift  the  upper  lip,  divide  the  mucous  mem- 
brane and  periosteum  at  the  point  of  flexion  above  the  root  of 
the  three  anterior  molars,  lift  the  periosteum  upward  and  out- 
ward with  the  elevator  to  below  the  infra-orbital  foramen,  and 
cut  through  the  thin  bony  wall  with  the  hollow  chisel.  The 
two  strong  bony  ridges  beside  the  canine  fossa,  namely,  the 
frontal  process  and  the  edge  of  the  zygoma,  are  left  intact. 

A  second  mode  is  an  upward  opening  with  a  perforator 
through  the  alveola  of  a  missing  or  drawn  tooth,  preferably  the 
third  or  fourth  molar. 

20.  A  third  method  of  opening  the  antrum  without  a  cuta- 
neous incision  is  from  the  nose.  The  thin  median  wall  of  the 
sinus  is  perforated  exactly  below  the  middle  of  the  lower  tur- 
binated body  from  the  lower  nasal  fossa,  with  a  curved-pointed 
instrument  (Mikulicz).  This  method  has  the  advantage  that 
the  pus  does  not  escajDe  into  the  mouth,  but  into  the  nose.  Its 
drawback  is  that  it  does  not  open  the  lowest  part  of  the  antrum 
as  do  the  operations  through  the  mouth.  The  two  last-men- 
tioned methods  do  not  permit  direct  inspection,  or  palpation  of 
the  antrum  with  the  finger.  But  this  is  possible  in  opening- 
through  the  canine  fossa. 

Operations  on  the  Nerves  of  the  Face. 

21.  The  Facial  Nerve  (see  Fig.  22). — The  surgeon  is  called 
upon  to  expose  the  facial  nerve  in  order  to  protect  it  during 
operations  in  the  retro -maxillary  fossa,  as  in  excision  of  swollen 


66  OPERATIVE   SURGERY. 

lymphatic  glands  and  tumors  of  the  parotid.  Besides,  the  facial 
is  occasionally  exposed  in  order  to  stretch  it  in  cases  of  spasm 
of  the  facial  muscles.  The  guiding  points  for  the  incision  are 
the  anterior  margin  of  the  mastoid  process  and  the  posterior 
margin  of  the  maxilla  (Hiiter,  Lobker,  Kauf mann) .  The  lobe 
of  the  ear  is  divided  at  its  anterior  edge  as  far  as  the  auricle 
along  the  point  of  attachment ;  this  incision  is  prolonged  down- 
ward to  behind  the  angle  of  the  jaw;  the  point  where  the  facial 
nerve  comes  forward  corresponds  about  to  the  middle  between 
the  angle  of  the  jaw  and  the  zygomatic  arch.  The  skin  and  the 
parotid-masseteric  fascia  are  divided,  the  parotid  is  exposed  at 
its  posterior  margin  and  completely  drawn  forward.  The  ten- 
dinous fibres  of  the  attachment  of  the  sterno-mastoid  muscle  are 
then  visible  and  along  them  the  incision  is  carried  deeper  at  the 
anterior  circumference  of  the  mastoid  process.  The  facial  nerve 
is  seen  1  cm.  deeper,  where  it  emerges  from  the  stylomastoid 
foramen  toward  the  surface. 

The  Trigeminus  Nerve. — The  main  indications  for  exposure 
of  the  fifth  cranial  nerve  are  neuralgias.  For  finding  its  first 
branch  see  "Ligature  of  the  Supra -Orbital  and.  Frontal  Artery," 
pp.   34  and  35,  Figs.  26  and  27. 

22.  The  Second  Branch  of  the  Trigeminus  (see  Figs.  30  and 
31). — The  main  branch  of  this  nerve,  which  is  most  frequently 
attacked  by  neuralgia,  is  the  infra -orbital.  In  order  to  stretch 
it  the  mucous  membrane  at  the  point  of  transition  of  the  upper 
lip  may  be  divided  from  the  mouth  as  far  as  the  canine  fossa. 
Having  reached  the  periosteum,  this  is  lifted  upward  to  the 
infra-orbital  foramen.  One-half  centimetre  below  the  middle 
of  the  infra -orbital  margin  the  nerve  can  be  exposed  and 
stretched  with  an  aneurism  needle  and  vigorously  drawn  for- 
ward with  the  finger. 

A  very  good  method,  though  it  requires  an  external  incision, 
is  the  following :  Incision  in  the  course  of  our  normal  upper 
maxillary  incision  (Figs.  12  and  13),  beginning  0.5  cm.  below 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE. 


67 


the  median  end  of  the  infra-orbital  margin,  extending  some- 
what obliquely  downward  and  outward  to  the  most  prominent 
part  of  the  zygoma  so  as  to  strike  the  zygomatic  muscle  at  its 
origin,  and  spare  the  branches  of  the  facial  supplying  the  mus- 
cles below  and  the  orbicularis  oculi.     The  incision  goes  down  to 


Masseter  muscle 
Zygomatic  muscle 

'  Quadratus  labi; 
superioris  muscle 


Infra-orbital  nerve. 


Fig.  30. 


the  bone  and  divides  the  attachment  of  the  quadratus  labii 
superioris  muscle.  The  periosteum  is  turned  down  as  far  as 
the  point  of  emergence  of  the  nerve  from  the  infra-orbital 
canal,  where  it  is  to  be  isolated  from  the  infra-orbital  artery 
and  an  aneurism  needle  passed  around  it.  Above,  the  perios- 
teum is  turned  back  over  the  infra-orbital  margin  and  from  the 
floor  of  the  orbit  until  the  beginning  of  the  infra-orbital  canal 


68  OPERATIVE   SURGERY. 

is  felt  or  seen  (Wagner) ;  then  the  thick  upper  wall  of  the  canal 
is  chiselled  out  with  two  blows  of  the  instrument.  In  this  way 
the  nerve  can  be  exposed,  stretched,  or  resected  for  a  consider- 
able distance.  If  the  antrum  of  Highmore  has  not  been  opened, 
the  wound  will  certainly  heal  by  first  intention,  without  result- 
ing deformity ;  this  is,  however,  the  rule  even  after  opening  the 
antrum. 

If,  however,  a  permanent  result  is  to  be  obtained  in  opera- 
tions for  neuralgia,  the  second  branch  of  the  trigeminus  must 
be  resected  at  the  foramen  rotundum.  For  the  infra-orbital 
nerve  subdivides  into  the  orbital  and  the  superior  posterior  alveo- 
lar before  it  enters  the  orbit,  and  the  trunk  of  the  second  branch 
of  the  trigeminus,  the  supra-maxillary,  gives  off  in  the  spheno- 
palatine fossa,  besides  the  infra-orbital,  the  spheno -palatine  nerve 
which  passes  downward  to  the  nasal  ganglion.  The  latter  branch 
is  not  to  be  found  isolated,  but  some  of  the  twigs  of  the  infra- 
orbital can  be. 

23.  Resection  of  the  Orbital  (Zygomatic)  Nerve  (Fig.  30). — 
Incision  1  cm.  long  at  the  outer  margin  of  the  orbit,  running 
obliquely  outward  and  downward,  beginning  near  the  outer 
canthus  and  extending  to  the  bone.  The  periosteum  is  detached 
from  the  lateral  wall  of  the  orbit,  and  with  it  the  nerve  is  torn 
from  its  point  of  entry  into  the  orbital  surface  of  the  zygoma. 

The  superior  alveolar  nerves  have  been  isolated  in  the  fol- 
lowing manner  (von  Langenbeck).  After  lifting  the  lips  a 
large  incision  is  made  over  the  teeth  down  to  the  bone,  and  the 
saw  or  chisel  divides  the  lateral  wall  of  the  antrum  with  the 
mucous  membrane  from  the  nasal  cavity  to  the  pterygoid 
process. 

24.  In  proportion  as  operations  for  neuralgia  are  limited 
to  the  division  of  peripheral  branches  the  prospects  for  perma- 
nent recovery  become  less.  When,  however,  the  supra-maxillary 
nerve  is  exposed  at  the  foramen  rotundum  (Figs.  12,  13,  30, 
and  31),  the  only  branch  missed  is  the  recurrent  supra-maxillary 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE. 


69 


passing  to  the  dura  mater.     On  the  other  hand,  this  central 
operation  has  the  drawback  of  causing  paralysis  of  the  motor 
branches  of  the  facial  for  the  palatal  muscles,  which  enter  the 
nasal  ganglion  and  join  the  palatal  nerve  through  the  Vidian. 
The  foramen   rotundum   is   reached   with   difficulty.     Von 


Roof  of  the  antrum  { 

of  Highmore       ( 

Floor  of  the  orbit 

Attaching  fibres  of  / 

niasseter  muscle    ( 

Posterior  surface  ) 

of  the  zygoma    \ 

Intra-orbital  nerve 

Antrum 


Orbicularis  muscle 
j  Supra-maxillary 
/  nerve 

Orbital  fat 


Fig.  31. 


Langenbeck  inserts  a  tenotome  at  the  external  orbital  margin 
under  the  external  palpebral  ligament.  This  method  has  been 
abandoned  because  it  does  not  guard  against  incidental  injuries 
and  wounds  the  infra-orbital  artery.  For  this  reason  resection 
of  the  zygoma  is  now  generally  practised  (Liicke,  Lossen, 
Braun).  On  the  principle  that  all  incisions  are  incorrect  which 
run  across  the  branches  of  the  facial,  we  proceed  in  the  follow- 
ing manner.     Incision  as  for  exposing  the  infra-orbital  nerve 


70  OPERATIVE   SURGERY. 

(see  Figs.  12  and  13),  but  longer,  i.e.,  beginning  1  cm,  in  a 
median  direction  from  the  palpable  infra-orbital  foramen,  run- 
ning somewhat  obliquely  downward,  but  mainly  horizontally 
outward  over  the  lower  part  of  the  zygoma  to  the  anterior  edge 
of  the  masseter  muscle.  At  the  inner  end  of  the  incision  the 
angular  artery  and  at  the  lateral  end  the  transverse  artery  of 
the  face  are  drawn  down  or  ligated;  Steno's  duct  remains 
below.  At  the  median  end  the  incision  passes  down  to  the  bone 
between  the  lower  margin  of  the  orbicularis  oculi  muscle  and 
the  origin  of  the  quadra tus  labii  superioris ;  the  former  muscle 
is  lifted  off  with  the  periosteum  as  far  as  the  orbit,  the  latter  is 
detached  under  the  periosteum  until  the  infra-orbital  nerve  is 
exposed,  where  it  emerges  from  the  canal  of  the  same  name  and 
can  be  grasped  with  an  artery  tenaculum. 

The  lateral  portion  of  the  incision  passes  above  the  attach- 
ment of  the  zygomatic  muscles  to  the  anterior  edge  of  the  mas- 
seter. The  former  are  divided  at  their  origin,  and  the  foremost 
portion  of  the  attachment  of  the  masseter  to  the  lower  and 
inner  surface  of  the  zygoma  is  detached. 

The  body  of  the  zygoma  is  freed  inward  and  outward  in  a 
vertical  direction  by  means  of  an  elevator  (Fig.  27)  so  as  to  be 
chiselled  through.  The  zygomatic  process  of  the  upper  maxilla 
is  freed  at  its  anterior  surface  to  the  infra-orbital  foramen,  at 
its  posterior  surface  to  the  inferior  orbital  fissure  so  that  the 
upper  wall  of  the  infra-orbital  canal  can  be  lifted  with  it,  and 
the  infra -orbital  nerve  drawn  with  a  hook  in  a  median  direction 
through  its  entire  length.  Then  the  upper  maxilla  is  chiselled 
through  so  that  the  orbital  plate  and  the  lateral  wall  of  the 
antrum  together  with  its  posterior  angle  remain  in  connection 
with  the  zygoma  and  can  be  lifted  with  it. 

In  order  to  effect  luxation  of  the  zygoma,  the  connection  of 
the  frontal  bone  with  the  zygoma  is  exposed  by  a  small  incision 
(see  Fig.  30),  and  the  chisel  carried  through  to  the  posterior 
part  of  the  inferior  orbital  fissure  so  that  it  is  possible  to  remove 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE.  71 

simultaneously  also  its  upper  border,  namely,  the  crista  zygomat- 
ica  and  orbitalis  of  the  sphenoid  bone.  The  zygoma  is  luxated 
ujDward  and  outward  from  the  large  wound  by  means  of  a 
strong,  sharp  hook,  the  orbital  fat  is  carefully  lifted  with  a  blunt 
hook,  and  then  it  is  easy  to  follow  the  tense  infra-orbital  nerve 
across  the  gaping  Highmorian  cavity  to  the  foramen  rotundum, 
and  to  introduce  a  small  hook,  behind  the  spheno-palatine  nerve 
which  runs  vertically  downward,  around  the  main  trunk  and  to 
divide  it,  or  tear  it  as  Thiersch  does.  The  infra-orbital  artery 
is  torn  when  the  zygoma  is  detached  and  luxated ;  the  hemor- 
rhage is  arrested  by  tampons.  At  the  end  of  the  operation  the 
zygoma  is  replaced.  No  bone  sutures  are  needed  for  its  fixa- 
tion. Then  the  cutaneous  wound  is  closed.  The  cicatrix  causes 
absolutely  no  disfigurement. 

The  third  branch  of  the  trigeminus  (Figs.  32  and  33)  at  the 
foramen  ovale  contains  both  portions,  namely,  the  motor  (pos- 
tero-externally)  and  the  sensory,  so  closely  intertwined  that 
they  cannot  be  separated.  Hence  a  central  division  of  the  nerve 
has  the  drawback  of  an  incidental  injury  which  is  not  intended, 
namely,  unilateral  paralysis  and  atrophy  of  the  muscles  of  mas- 
tication. Fortunately  experience  (our  own  included)  shows  that 
this  unilateral  paralysis  per  se  does  not  seriously  limit  the  func- 
tion of  the  maxilla ;  it  merely  lessens  the  force  of  the  closure  of 
the  jaw  and  the  amplitude  of  the  lateral  motions.  Still  the 
above  drawback  connected  with  the  division  of  the  trunk  at  the 
foramen  ovale  would  justify  the  attempt  to  stretch  or  divide 
only  single  branches  in  neuralgia,  despite  the  uncertainty  of  the 
result. 

Particularly  the  lingual  and  the  alveolar  nerves  are  fre- 
quently the  seat  of  neuralgias,  especially  the  latter  in  its  course 
through  the  infra-maxillary  canal,  from  which  it  again  emerges 
as  the  mental  nerve.  Besides  we  occasionally  meet  with  neur- 
algias in  the  auriculo-temporal  and  the  buccinator  nerves  which 
supply  the  region  of  the  angle  of  the  mouth. 


72  OPERATIVE    SURGERY. 

The  inferior  alveolar  nerve  (Fig.  28)  can  be  rendered  acces- 
sible at  different  points. 

25,  If  the  terminal  branch  alone,  the  mental  nerve  (Fig.  28), 
is  sought,  the  lower  lip  is  vigorously  pulled  away  from  the 
maxilla,  the  mucous  membrane  is  incised  vertically  at  its  turn- 
ing-point under  the  interstices  of  the  first  and  second  premolar 
teeth  of  the  lower  jaw,  the  periosteum  is  divided,  and  the  nerve 
is  seen  to  emerge  from  the  mental  foramen.  Usually,  however, 
the  seat  of  the  neuralgia  is  higher  up  in  the  region  of  the  teeth. 
Hence  the  nerve  must  be  exposed  before  it  enters  the  infra- 
maxillary  canal.  To  reach  it  there  two  methods  have  been 
chiefly  employed. 

26.  Inferior  Alveolar  Nerve  (Fig.  29). — a.  Trephining  of 
the  ascending  ramus  by  an  incision  at  the  margin  of  the  angle 
of  the  jaw.  But  at  this  very  point  run  the  branches  of  the 
facial  which  supply  the  muscles  of  the  chin  and  lower  lip. 
Hence  the  angle  of  the  jaw  must  be  approached  by  a  curved 
incision,  the  marginal  branch  being  withdrawn  and  the  facial 
carefully  dissected  out  (compare  the  posterior  part  of  our  nor- 
mal incision  for  the  upper  cervical  triangle,  Fig.  29).  Then 
the  fibres  of  the  masseter  are  partly  detached  upward  from  the 
maxilla  by  means  of  the  elevator  without  cutting,  the  muscle 
together  with  the  upper  margin  of  the  wound  is  held  up  with  a 
blunt  hook,  and  a  piece  of  bone  is  chiselled  out  exactly  in  the 
middle  of  the  ascending  ramus  (Velpeau,  Linhardt),  Thus  we 
reach  at  the  inner  surface  of  the  maxilla  the  point  of  entry  of 
the  nerve.  This  method  is  very  exact  and  we  are  sure  of  strik- 
ing the  nerve.  If  healing  ensues  by  first  intention,  the  func- 
tion of  the  maxilla  remains  unimpaired. 

h.  Paravicini's  method.  The  mouth  being  opened  wide 
(White's  speculum),  we  palpate  at  the  anterior  margin  of  the 
ascending  ramus  of  the  jawbone  its  sharp  inner  edge  upon 
which  we  divide  the  mucous  membrane  and  periosteum  down 
to  the  bone.     The  inner  margin  is  sufficiently  detached  subperi- 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE.  73 

osteally  with  a  blunt  instrument  from  the  inner  surface  of  the 
ascending  ramus  until  the  lingula  is  felt  as  a  pointed  projection 
at  the  inner  circumference  of  the  infra-maxillary  canal.  Be- 
hind this  the  nerve  is  sure  to  be  found.  The  operation  is  ex- 
ceedingly simple  and  far  less  serious  than  that  from  without; 
but  it  has  the  drawback  of  necessitating  a  wound  in  the  mouth 
which  possibly  may  be  infected,  while  in  operations  from  with- 
out infection  can  be  positively  prevented.  The  slower-  heal- 
ing of  an  infected  wound,  and  the  fact  that  the  internal  liga- 
ment is  attached  at  the  lingula,  may  have  the  consequence 
that  the  opening  of  the  mouth  is  for  some  time  interfered 
with. 

27.  The  lingual  nerve  can  be  exposed  after  Paravicini's  in- 
trabuccal  method.  The  following  procedure  is  simpler.  At  the 
point  where  the  nerve  passes  forward  between  the  anterior  pala- 
tine arch  and  the  base  of  the  tongue  it  is  situated  very  super- 
ficially under  the  mucous  membrane.  Therefore  only  a  small 
longitudinal  incision  is  needed  to  expose  it  with  certainty.  The 
opening  should  not  be  too  near  the  tongue.  The  transverse 
division  of  the  cheek  after  Roser  is  not  a  necessary  preliminary. 
The  operation  has  the  disadvantage  that  a  wound  is  made  inside 
the  oral  cavity. 

In  order  to  avoid  this,  the  attempt  has  been  made  to  expose 
the  nerve  from  without  and  below  at  the  point  where  it  passes 
above  the  submaxillary  gland.  The  incision  (part  of  our  nor- 
mal incision  for  the  upper  cervical  triangle)  at  the  neck  simply 
exposes  the  submaxillary  gland  at  its  lower  margin.  The  gland 
is  turned  upward  and  the  nerve  is  grasped  at  the  j)oint  where 
it  is  in  connection  with  the  submaxillary  gland  through  the 
lingual  ganglion.  The  operation  is  far  more  difficult  than  the 
former,  but  it  has  the  advantage  that  healing  by  first  intention 
is  certain  to  be  obtained.  Thirdly,  the  nerve  can  be  found,  like 
the  inferior  alveolar  nerve,  by  trephining  of  the  ascending 
ramus  of  the  maxilla. 


74 


OPERATIVE    SURGERY. 


28.  The  auriculo -temporal  nerve  (see  Figs.  10  and  11)  is 
exposed  at  the  posterior  surface  of  the  temporal  vessels  under 
which  it  passes  upward.  A  longitudinal  incision  from  the  root 
of  the  zygomatic  arch  upward  through  skin  and  fascia  renders 
the  thin  nerve  trunk  accessible. 

29.  The  buccinator  nerve  is  the  sensory  nerve  for  the  region 


Fat 


aporal  muscle 
jomatic  arch 

ttachment  of  the 
masseter 


Fig.  32. 


of  the  angle  of  the  mouth.  It  lies  at  the  inner  side  of  the  cor- 
onoid  process  of  the  lower  maxilla.  The  nerve  can  be  grasped 
at  the  anterior  margin  of  the  process,  both  in  operating  from 
without  and  from  within.  The  operation  from  within  is  more 
simple.  After  opening  the  mouth  wide,  the  edge  at  the  an- 
terior margin  of  the  process  named  is  felt  without  difficulty ;  we 
cut  down  upon  it,  dividing  the  mucous  membrane  and  the  fibres 
of  the  buccinator  muscle.  The  nerve  passes  transversely  for- 
ward upon  the  process. 

The  operation  from  without  (Zuckerkandl)  is  effected  by  an 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE. 


75 


incision  below  the  zygomatic  arch  and  bone,  extending  forward 
from  the  anterior  margin  of  the  masseter  in  a  horizontal  direc- 
tion above  Steno's  duct,  the  transverse  facial  artery  being  left 
intact  (Fig.  22) ;  at  the  anterior  margin  of  the  masseter  we 
strike  the  mass  of  fat  of  the  cheek ;  after  this  is  pushed  aside  or 
removed,  we  reach  the  anterior  margin  of  the  coronoid  process 


i  External  surface  of  the 
I  sphenoid  bone 

i  External  surface  of  the 
'  temporal  bone 

Crista  iufra-temporalis 
Infra-maxillary  nerve 


Cut  surface  of  I 

the  zygoma     C 

Temporal  muscle 


(  Attachment  to  the  zy- 
-.     g-omaJc  arch  of  the 
(     massetfr 
Zygoma  drawn  down 


Fig.  33. 


on  the  inner  side  of  which  the  nerve  passes  forward  upon  the 
fibres  of  the  buccinator  muscle. 

30.  Infra- Maxillary  Nerve. — All  operations  on  the  branches 
of  the  third  trunk  of  the  trigeminus  are  so  often  followed  by 
relapses  that  nothing  is  left  but  to  look  for  the  third  trunk  of 
the  trigeminus  at  the  foramen  ovale  (Figs.  24,  25,  32,  33). 
This  operation  is  most  certain  in  its  results  if  the  zygomatic 
arch  is  resected  (Lilcke,  Braun,  Lossen,  Kronlein). 

We  adhere  to  the  rule  that  here,  too,  only  those  incisions  must 
be  made  which  avoid  injury  of  the  branches  of  the  facial  nerve. 


76  OPERATIVE   SURGERY. 

The  incision  begins  behind  the  frontal  process  of  the  zygoma 
and  is  carried  obhquely  downward  as  far  as  the  posterior  end  of 
the  zygomatic  arch.  From  the  posterior  end  of  this  incision 
another  one  is  carried  down  to  the  bone  at  a  right  angle,  rising 
obliquely  backward  in  front  of  the  ear  (ligature  of  the  temporal 
artery  and  vein).  We  divide  the  skin,  some  fibres  of  the  orbi- 
cularis, and  the  tense  temporal  fascia,  which  is  drawn  down, 
together  with  the  branches  of  the  facial  nerve  supplying  the  eye 
and  forehead.  Immediately  behind  the  ascending  frontal  pro- 
cess of  the  zygoma  the  latter  is  now  exposed  in  a  vertical  line 
within  and  without,  and  chiselled  through.  At  the  posterior 
end  of  the  zj^gomatic  arch  its  root  is  likewise  divided  close  to 
its  origin,  and  the  arch  drawn  down  with  a  strong  hook. 

The  outer  surface  of  the  temporal  muscle,  covered  with  fat, 
is  now  laid  bare.  This  muscle  is  lifted  from  the  skull  by  its 
posterior  margin  and  drawn  vigorously  forward  with  a  blunt 
hook.  Only  if  the  access  gained  is  insufficient  is  the  attach- 
ment of  the  muscle  at  the  coronoid  process  divided,  or  else  the 
point  of  this  process  is  severed  with  cutting  forceps  when  prop- 
erly isolated  (Kronlein).  It  is  not  a  matter  of  special  impor- 
tance that  the  muscle  be  spared ;  but  detachment  diminishes  the 
injury  as  compared  with  cutting,  and  gives  a  clearer  field  of 
operation.  Then  the  periosteum  -  along  the  crista  infra-tem- 
poralis  is  divided  from  the  anterior  edge  of  the  origin  of  the 
zygomatic  arch  at  the  temporal  bone  and  all  the  soft  parts  to- 
gether are  lifted  subperiosteally  from  the  lower  surface  of  the 
skull  in  a  median  direction.  Thus  we  reach  without  further 
injury  the  outer  surface  of  the  base  of  the  pterygoid  process, 
and  behind  its  sharp  posterior  edge  the  foramen  ovale  is  dis- 
tinctly palpable,  about  3  cm.  deeper  than  the  temporal  origin  of 
the  zygomatic  arch.  Occasionally  there  are  two  openings  from 
which  the  nerve  emerges.  The  large  arteries,  branches  of  the 
internal  maxillary,  remain  in  the  soft  parts  which  have  been 
turned  down,  with  the  exception  of  the  middle  meningeal  which 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE.  77 

lies  posteriorly.  The  zygomatic  arch  is  replaced  and  fastened, 
and  the  resulting  cicatrix  is  almost  invisible.  It  is  unnecessary 
to  resect  the  zygoma,  in  addition,  at  its  orbital  plate  or  as  far 
as  its  junction  with  the  upper  maxilla,  for  no  more  room  is 
gained  thereby  for  the  isolation  of  the  nerve. 

31.  Resection  of  the  Upper  Maxilla  (see  Figs.  22  and 
23). — If  the  surgeon  is  to  have  courage  enough  to  perform  pnv- 
tial  or  total  resection  of  the  upper  maxilla  with  the  necessary 
thoroughness  in  the  early  beginning  of  malignant  new-forma- 
tions, that  is  to  say,  to  expose  the  diseased  i3art  so  perfectly  that 
all  suspicious  tissues  can  be  removed,  he  requires  to  be  ac- 
quainted with  operations  which  are  not  followed  by  serious  dis- 
figurement. Especially  facial  expression  should  not  be  injured 
unnecessarily.  The  aim,  therefore,  is  not  only  to  secure  small 
cicatrices,  but  the  facial  muscles  and  particularly  their  motor 
nerves  must  be  kept  intact.  In  order  to  attain  this,  the  follow- 
ing procedure  is  to  be  recommended.  A  median  incision  is 
made  (see  Fig.  22)  which  passes  upward  beside  the  filtrum  from 
the  slight  depression  in  the  upper  lip  into  the  nostril,  from  the 
nostril  close  around  the  ala  nasi,  along  the  jDyriform  aperture 
obliquely  upward  and  in  a  median  direction  to  the  junction  of 
the  nasal  bone  with  the  upper  maxilla  as  far  as  the  height  of 
the  inner  canthus  or  to  the  root  of  the  nose.  In  this  way  only 
the  levator  alse  nasi  is  divided,  which  is  of  no  consequence  in 
facial  expression. 

Should  the  incision  described  prove  insufficient  to  permit  a 
good  view,  it  may  be  enlarged  as  follows.  Entering  between 
the  upper  and  the  lower  fields  supplied  by  the  facial  nerve,  a 
transverse  incision  is  added  which  runs  laterally  and  slightly 
downward,  from  the  lower  margin  of  the  orbicularis  oculi  mus- 
cle across  the  attachments  of  the  quadratus  labii  superioris  and 
the  zygomatic  muscles  (our  normal  upper  maxillary  incision 
below  the  infra-orbital  margin.  Fig.  22).  The  entire  flap  to 
gether  with  all  the  healthy  soft  parts  and  nerve  twigs  is  turned 


78  OPERATIVE   SURGERY. 

outward  and  the  bone  or  the  tumor  laid  bare.  By  grasping  the 
base  of  the  turned  flap  sufficient  compression  can  be  exerted  and 
the  vessels  easily  and  safely  ligated  (angular,  labial,  and  infra- 
orbital artery,  possibly  the  transverse  facial) .  Immediate,  thor- 
ough arrest  of  hemorrhage  is  an  eminently  important  factor  in 
operating  correctly.  For  this  reason  and  the  loss  of  blood  in 
general,  a  preliminary  ligation  of  the  external  carotid  artery  is 
to  be  highly  recommended  in  resection  of  the  upper  maxilla  and 
renders  the  operation  much  cleaner  and  easier. 

The  upper  maxilla  is  then  freed  from  its  attachments.  With 
the  chisel  or  cutting  forceps  we  divide,  in  extensive  disease,  the 
frontal  process  of  the  upper  maxilla  together  with  the  nasal 
iDone  from  the  upper  part  of  the  pyriform  aperture  backward, 
passing  through  the  lachrymal  and  ethmoid  bones  to  the  pos- 
terior end  of  the  inferior  orbital  fissure,  in  the  course  of  which 
no  serious  injuries  are  inflicted.  For  the  connection  of  the 
upper  maxilla  with  the  zygoma  we  make  the  division,  according 
to  the  indications,  either  at  the  point  just  named,  or  else  the 
zygoma  is  removed  altogether  with  a  vigorous  blow  of  the 
chisel,  after  dividing  the  zygomatic  arch  and  the  frontal  process 
of  that  bone  through  a  separate  small  incision.  During  this 
step  the  wound  margins  must  be  drawn  vigorously  aside  with 
sharp  hooks.  There  remains  the  third  connection  with  the 
upper  maxilla  of  the  opposite  side.  The  chisel  is  applied  medi- 
ally between  the  incisors,  and  the  plate  of  the  palate  throughout 
its  entire  length  is  cut,  after  the  mucous  membrane  and  perios- 
teum of  the  palate  at  the  limit  of  the  disease  has  been  divided 
down  to  the  bone  and  the  soft  palate,  too,  separated  transversely 
from  its  attachments,  with  the  knife  or,  better,  the  thermo- 
cautery. 

Lastly  we  have  the  connection  with  the  pterygoid  process. 
If  the  flap  is  vigorously  drawn  back,  the  soft  parts  can  be 
divided  from  without  as  far  as  this  process,  with  the  necessary 
control  of  the  hemorrhage,  i.e.,  mucous  membrane,  buccinator, 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE.  79 

external  and  internal  pterygoid  muscles;  then  the  bony  process 
is  cut  from  without  with  the  chisel,  the  flap  containing  the  soft 
parts  being  drawn  out  of  the  way.  Where  this  bone  is  not  to 
be  removed  its  connection  with  the  maxilla  is  broken  by  draw- 
ing the  latter  strongly  downward ;  this  should  be  done  quickly 
so  that  the  bleeding  may  be  arrested.  For  during  this  act  the 
large  terminal  branches  of  the  internal  maxillary  artery  are  torn 
(the  spheno-palatine,  pterygo-palatine,  and  infra -orbital  arteries). 

32.  Less  radical  is  the  osteoplastic  total  resection  of  the 
upper  maxilla,  during  which  the  jaw  is  bent  out  and  again 
replaced.  This  operation  is  indicated  in  tumors  of  the  base  of 
the  skull  (os  basilare  and  its  neighborhood),  especially  in  retro- 
maxillary  tumors,  when  sufficient  room  cannot  be  gained  by 
Gussenbauer's  method  of  dividing  the  soft  palate  and  chiselling 
out  the  hard  palate.  The  difference  between  this  and  the  pre- 
ceding operation  consists  in  the  fact  that  after  the  cutaneous 
incisions  the  soft  parts  are  not  detached  from  the  bone;  but, 
the  bony  connections  having  been  severed,  the  maxilla  is  bent 
over  laterally  together  with  the  soft  parts.  The  frontal  process 
of  the  zygoma  must  be  severed  through  a  special  oblique  inci- 
sion, in  like  manner  as  in  the  above -described  method  of  resec- 
tion of  the  supra-maxillary  nerve  at  the  foramen  rotundura 
(see  Fig.  30). 

For  exposing  the  retro-maxillary  fossa  use  is  made  of  the 
method  of  resection  of  the  zygoma  described  in  connection  with 
the  division  of  the  second  trunk  of  the  trigeminus. 

When  only  the  nasal  cavity,  alone  or  with  the  antrum  of 
Highmore,  is  to  be  rendered  accessible,  a  partial  osteoplastic 
resection  of  the  upper  maxilla  (Fig.  23)  suffices  and  is  performed 
as  follows.  Cutaneous  incision  as  for  resection  of  the  upper 
maxilla,  except  that  the  upper  lip  is  not  split  (Fig.  28),  that  is 
to  say,  from  the  nostril  around  the  ala  nasi  up  to  near  the  inner 
canthus  and  beneath  the  infra-orbital  margin  across  to  the 
.zygoma. 


80  OPERATIVE   SURGERY. 

Starting  from  the  upper  end  of  the  pyriform  aperture  the 
parts  are  severed  in  the  following  order:  First  the  connection 
of  the  nasal  bone,  laterally  the  junction  of  the  latter  and  of  the 
frontal  process  of  the  upper  maxilla  and  that  of  the  lachrymal 
bone  with  the  frontal  bone,  then  obliquely  backward  and  down- 
ward the  orbital  plate  of  the  cribriform  bone  as  far  as  the  infe- 
rior orbital  fissure,  by  means  of  the  bone  forceps  or  a  fine  chisel. 
From  the  lowest  portion  of  the  pyriform  aperture  the  chisel 
divides  the  median  and  anterior  wall  of  the  antrum  to  the  infra- 
orbital canal ;  finally  backward  along  the  latter  the  orbital  plate 
of  the  upper  maxilla,  from  the  horizontal  cutaneous  incision. 
Then  the  bones  with  the  soft  parts  can  be  turned  outward,  thus 
exposing  as  a  single  space  the  nasal  cavity  and  that  of  the 
antrum  of  Highmore. 

We  have  stated  in  connection  with  the  nasal  operations  (p. 
63)  how  by  a  simple  cut  through  the  upper  lip  and  a  median 
incision  through  the  hard  and  soft  palate,  the  two  halves  of  the 
upper  maxilla  can  be  opened  and  the  base  of  the  skull  rendered 
accessible. 

33.  Eesection  of  the  Lower  Maxilla. — This  operation  is 
a  simple  one,  but  even  here  unnecessary  disfigurement  due  to 
lesion  of  the  oral  branch  of  the  facial,  especially  its  marginal 
ramus,  should  be  avoided. 

As  the  simplest  may  be  recommended  the  median  incision 
(Fig.  23),  v/hich  divides  the  lower  lip  and  eventually  extends  to 
the  middle  of  the  hyoid  bone.  This  incision  alone  gives  ample 
room  in  disease  of  the  middle  portion  and  a  large  part  of  the 
horizontal  rami  of  the  lower  maxilla.  In  disease  affecting  the 
region  of  the  angle  of  the  jaw  and  the  ascending  ramus,  and 
when  it  is  necessary  to  expose  and  clear  the  submandibular 
fossa  of  malignant  new-formations,  a  lateral  incision  is  added. 
This  should  not  be  placed,  as  is  often  done,  at  the  margin  of  the 
maxilla,  on  account  of  the  branches  of  the  facial  passing  there ; 
but  it  should  be  carried  from  the  hyoid  bone,  extending  back- 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE.         81 

ward  and  upward  in  the  fold  between  the  floor  of  the  mouth 
and  the  neck,  the  width  of  the  thumb  behind  and  below  the 
angle  of  the  jaw,  if  necessary  as  far  as  the  tip  of  the  mastoid 
process  (compare  our  normal  incision  for  the  upper  cervical 
triangle.  Fig.  29).  The  flap  limited  by  these  incisions  is  turned 
up  and  fastened  to  the  skin  of  the  face  with  sutures.  Withal 
the  surgeon  must  keep  as  close  as  possible  to  the  bone,  and 
detach  the  muscles  with  the  flap  (anteriorly  the  mental,  trian- 
gulai'is  and  quadrangularis  mentis  muscles,  posteriorly  the 
buccinator  and  masseter).  On  the  inner  surface  of  the  maxilla 
the  muscles  detached  are,  anteriorly  the  digastric,  genio-hyoid, 
mylo-hyoid,  and  genio-glossus,  posteriorly  the  internal  ptery- 
goid. 

Before  the  muscles  are  detached  it  is  proper  to  saw  through 
the  maxilla  in  front  so  that  it  can  be  vigorously  drawn  forward 
and  the  soft  parts  rendered  tense.  After  the  muscles  and  the 
mucosa  are  divided  the  maxilla  is  drawn  down  so  that  the  cor- 
onoid  process  may  be  seen  and  felt.  Its  point  is  removed  with 
cutting  forceps  and  thus  the  attachment  of  the  temporal  muscle 
severed.  The  head  and  neck  of  the  maxilla  are  not  freed  with 
sharp  instruments,  lest  the  internal  maxillary  artery  be  injured ;; 
but  after  all  the  other  connections  have  been  divided  the  head 
is  simply  twisted  out  and  the  joint  capsule  and  the  external 
pterygoid  muscle  are  torn  by  torsion.  The  external  maxillary 
artery  has  been  severed  and  tied  during  the  turning  over  of  the 
flap  composed  of  soft  parts.  When  the  horizontal  portion  of  the 
maxilla  is  sawn  through,  the  inferior  alveolar  artery  is  lacer- 
ated in  the  infra-maxillary  canal  and  tamponed  with  a  plug  of 
wax;  should  one-half  of  the  maxilla  be  totally  removed,  the 
artery  is  ligated  in  the  posterior  upper  angle  of  the  wound, 
either  before  or  after  the  maxilla  is  twisted  off  or  while  the 
internal  pterygoid  is  detached. 

The  inferior  alveolar  nerve  is  torn  or  else  it  is  divided  when 

the  internal  pterygoid  muscle  is  detached. 
6 


82  OPERATIVE   SURGERY. 

In  this  operation,  as  in  resection  of  the  upper  maxilla,  it  is 
advisable,  as  soon  as  the  cutaneous  incision  has  been  made,  to 
ligate  the  external  carotid  artery  above  the  superior  thyroid  or 
possibly  above  the  point  where  the  lingual  artery  branches  off. 

34.  Osteoplastic  resection  of  the  lower  maxilla  is  an  impor- 
tant preliminary  operation  for  exposing  the  floor  of  the  mouth, 
the  root  of  the  tongue,  the  isthmus  of  the  fauces,  and  the  tis- 
sues in  the  lower  pharynx.  Satisfactory  access  is  gained  to 
the  tissues  situated  in  front  of  the  isthmus  of  the  fauces  by  the 
median  division  of  the  lip  and  the  lower  maxilla.  This  opera- 
tion has  the  great  advantage  that,  if  exactly  sutured  with  iron 
wire,  the  movements  of  the  lower  jaw  are  not  even  temporarily 
hampered  to  any  notable  extent,  and  the  fragments  knit  readily 
if  well  coaptated. 

For  cases  requiring  division  of  the  maxilla  in  disease  around 
the  isthmus  of  the  fauces  and  in  the  pharyngeal  tissues  situated 
behind  it,  the  normal  procedure  is  division  of  the  maxilla  in 
front  of  the  ascending  ramus.  The  incision  is  like  that  for 
resection  of  the  lower  maxilla,  in  a  line  from  the  mastoid 
process  toward  the  hyoid  bone,  the  length  being  adapted  to  the 
requirements.  After  ligature  of  the  internal  maxillary  artery 
at  the  anterior  circumference  of  the  masseter  the  lower  margin 
of  the  maxilla  is  exposed,  the  periosteum  is  detached  forward 
and  backward,  the  mucous  membrane  is  torn  with  the  elevator, 
and  the  bone  is  divided  with  the  fret-saw  behind  the  molars. 

Before  this  last  step  it  is  proper  to  make  one  or  two  drill 
openings  for  the  subsequent  suture  with  iron  wire.  The  saw 
should  move  obliquely  so  that  the  external  lower  side  is  farther 
forward  than  the  inner  and  upper,  for  the  posterior  end  of  the 
maxilla  tends  to  be  displaced  medially  and  upward.  The  as- 
cending ramus  is  now  turned  upward  with  a  sharp  hook,  and 
the  anterior  portion  of  the  maxilla  is  drawn  forward. 

35.  The  oral  and  pharyngeal  organs  can  also  be  made  acces- 
sible without  osteoplastic  resection  of  the  lower  maxilla.     An 


OPERATIONS  ON  THE  NERVES  OF  THE  FACE.  83 

excellent  method  is  the  transverse  incision  of  the  cheek  recom- 
mended by  Roser  for  exposure  of  the  lingual  nerve  (see  Fig.  22). 
This  incision  extends  from  the  angle  of  the  mouth  transversely 
backward,  parallel  to  the  branches  of  the  facial  nerve,  as  far  as 
the  prominence  of  the  masseter,  all  the  soft  parts  being  divided 
(skin,  orbicularis  oris  and  buccinator  muscles,  and  mucous 
membrane).  Of  course  this  incision  leaves  a  cicatrix  with  sub- 
sequent retraction,  but  the  resulting  disfigurement  is  unimpor- 
tant, since  the  expression  is  in  no  way  restricted,  thanks  to  the 
preservation  of  all  the  branches  of  the  facial.  Steno's  duct  and 
the  transverse  facial  artery  remain  above  the  incision,  but  the 
external  maxillary  artery  is  cut  and  requires  double  ligature, 

36.  Incisions  in  the  Tongue  and  the  Floor  of  the  Mouth. — 
These  should  not  be  made  except  after  thorough  opening  of  the 
mouth  with  proper  specula  (White's),  the  tongue  being  drawn 
forward  with  a  loop  of  thread  intro'duced  deeply  through  its  sagit- 
tal median  line.  Thorough  opening  of  the  mouth  presupposes 
profound  anaesthesia,  especially  if  the  motion  of  the  jaw  is  re- 
stricted by  inflammation  or  other  painful  infiltration  of  the  soft 
parts  between  the  upper  and  lower  maxilla  or  in  the  region  of 
the  latter.  Incisions  can  be  made  on  the  dorsum  of  the  tongue 
without  fear  of  injuring  the  larger  vessels  and  nerve  trunks. 
The  median  line  is  to  be  preferred,  as  here  the  damage  is  least. 

Laterally  and  on  the  floor  of  the  mouth  are  large  vessels 
(the  lingual  and  sublingual  arteries  and  veins),  nerve  trunks 
(hypoglossus,  lingual,  and  behind  the  glosso-pharyngeus),  and 
the  efferent  ducts  of  the  salivary  glands  (Wharton's  and  Eiv- 
inus').  The  closer  the  incision  is  kept  to  the  maxilla  the  more 
certainly  are  these  structures  avoided.  Near  the  lateral  margin 
of  the  tongue,  under  the  prominence  of  the  lingual  muscle  and 
on  the  outer  side  of  the  genio-glossus  muscle,  the  lingual  artery 
and  nerve  can  be  exposed.  Posteriorly  the  artery  is  covered  by 
the  fibres  of  the  hyo-glossus  muscle.  Toward  the  tip  of  the 
tongue  the  vessels  approach  the  lower  surface.     Where  profuse 


84  OPERATIVE   SURGERY. 

hemorrhage  is  to  be  feared  from  incisions  about  the  tongue  a 
prophylactic  ligature  of  the  lingual  artery  is  to  be  recommended. 

G.  The  Upper  Lateral  Cervical  Triangle.' 

The  Normal  Incision  for  the  Upper  Cervical  Triangle. 

In  accordance  with  our  principle  to  place  cutaneous  incisions 
in  the  direction  in  which  the  skin  splits  naturally,  we  recom- 
mend for  the  exposure  of  the  organs  in  the  infra-  and  retro- 
mandibular fossa  an  incision  (Fig.  29)  already  indicated  for 
resection  of  the  maxilla;  namely,  passing  from  the  anterior  end 
of  the  tip  of  the  mastoid  process  to  the  middle  of  the  hyoid 
bone,  extending  a  finger's  breadth  below  and  behind  the  angle 
of  the  jaw,  and  intersecting  at  this  point  the  anterior  margin 
of  the  sterno-cleido-mastoid  muscle.  This  incision  has  the  great 
advantage  that  it  lies  on  the  border  line  where  the  muscles 
coming  from  above  and  below  meet  or  end,  in  so  far  as  they 
concern  the  organs  within  the  neck :  above,  the  digastric,  stylo- 
hyoid, genio-hyoid,  and  mylo-hyoid;  below,  the  sterno-hyoid, 
thyreo-hyoid,  and  omo-hyoid.  The  muscles  crossing  this  border 
line  are  either  unimportant  as  the  platysma,  or  they  remain  at 
the  side  or  behind  as  the  sterno-cleido-mastoid  and  the  muscles 
of  the  vertebral  column. 

Moreover,  this  incision  enables  us  to  avoid  the  important 
nerves  in  so  far  as  their  main  trunks  lie  either  above  or  behind 
or  can  be  drawn  aside,  while  their  branches  running  up  and 
down  radiate  from  the  direction  of  the  incision.  Thus  the 
vagus  and  sympathetic  lie  posteriorly  with  the  sterno-cleido- 
mastoid  muscle,  together  with  the  spinal  accessory  and  the  de- 
scending ramus  of  the  hypoglossal.  The  inferior  branch  of  the 
facial,  the  hypoglossal,  the  lingual,  and  the  glosso-pharyngeus 

'  For  practical  reasons  we  limit  it  above  by  the  margin  of  the  lower  maxilla, 
inward  by  the  median  line  as  far  as  the  upper  margin  of  the  thyroid  cartilage, 
and  backward  by  the  anterior  margin  of  the  sterno-cleido-mastoid  muscle. 


THE  UPPER  LATERAL  CERVICAL  TRIANGLE.         85 

are  above ;  the  superior  laryngeal  branch  of  the  vagus  is  drawn 
down. 

In  the  third  place  the  incision  strikes  the  points  where  the 
branching  of  the  large  vessels  of  the  neck  begins  and,  in  the 
main,  terminates.  At  the  level  of  the  upper  margin  of  the 
thyroid  cartilage  the  common  carotid  divides  and  immediately 
above  are  given  off  the  branches  of  the  external  carotid  in  close 
proximity.  At  the  same  level  the  anterior  and  posterior  facial 
veins  join  the  common  facial  vein,  and  the  latter  the  common 
jugular  vein.  Hence  from  the  normal  incision  the  great  num- 
ber of  branches  and  even  the  trunks  of  the  larger  vessels  of  the 
neck  can  be  ligated. 

For  this  reason  we  designate  this  incision  the  normal  one 
for  the  upper  cervical  triangle,  and  all  the  longer  and  shorter 
incisions  here  required  coincide  with  it. 

37.  External  and  Internal  Carotids  (Figs.  10  and  11). — The 
point  of  our  normal  incision  at  which  we  feel  the  pulsation  of 
the  artery  and  ligate  it  lies  at  the  anterior  margin  of  the  sterno- 
cleido- mastoid  muscle.  The  margin  of  this  m^^scle  ascends 
much  more  vertically  than  it  is  usually  represented ;  the  fascia 
draws  it  forward  toward  the  angle  of  the  jaw.  The  point  for 
our  ligature,  therefore,  lies  a  finger's  breadth  vertically  under 
the  angle  of  the  jaw.  Here  the  artery  ascends  vertically  from 
below.  For  its  exposure  we  employ  a  corresponding  portion  of 
our  normal  incision,  forward  and  backward  of  the  point  men- 
tioned. After  the  skin  the  platysma  is  divided,  which  often 
forms  quite  an  extensive  muscular  layer.  Its  fibres  pass  up- 
ward and  forward  over  the  margin  of  the  maxilla.  In  the  pos- 
terior portion  of  the  incision  the  external  jugular  vein  which 
passes  up  exactly  over  the  sterno-cleido-mastoid  muscle  is  not 
divided  but  drawn  back  with  the  large  auricular  nerve  that 
runs  behind  it.  By  dividing  the  fascia  the  anterior  margin  of 
the  sterno-cleido-mastoid  muscle  is  exposed,  and  then  appears 
the  common  facial  vein  as  far  as  its  termination  in  the  common 


86 


OPERATIVE   SURGERY. 


jugular  vein.  The  former  descends  over  the  digastric  muscle. 
These  veins  have  to  be  drawn  forward  and  downward;  their 
smaller  branches  must  be  ligated.  We  now  strike  the  external 
and  internal  carotid  arteries,  the  latter  lying  at  its  origin  pos- 
teriorly and  somewhat  more  superficially,  which  fact  is  apt  to 
lead  to  error.     The  internal  carotid  gives  off  no  branches,  while 


j  Temporal  artery 

( Auriculo-temporal  nerve 


{  External  and  internal  caro- 
J        tld  artery 
'   J  Hypoglossal  nerve 
(  Lingual  nerve 


Superior  thyroid  artery — 

Vertebral  artery  1 
Inferior  thyroid  artery  V  _ 
CEsophagotomy ) 


'^m 


Fiox.  34  A. 


the  external  is  characterized  by  a  branch,  the  superior  thyroid 
artery,  immediately  above  its  origin.  Hence  the  vessels  cannot 
be  mistaken  for  each  other.  Moreover,  the  external  carotid,  at 
the  point  where  the  external  maxillary  artery  is  given  off,  is 
surrounded  from  behind  and  without  by  the  hypoglossal  nerve. 
The  small  cleido-mastoid  artery  bends  backward  over  the  nerve. 
Ligature  of  the  external  carotid  is  not  easy,  since  its  guiding- 
points  consist  only  of  soft  parts  (anterior  margin  of  the  sterno- 


THE  UPPER  LATERAL  CERVICAL  TRIANGLE. 


87 


cleido-mastoid)  which  may  be  displaced  with  every  incision.  In 
exposing  the  artery  we  must  preserve  the  descending  hypo- 
glossal branch  which  supplies  the  muscles  of  the  sternum  and 
larynx. 

Through  the  same  incision  we  can  ligate  a  large  number  of 
the  branches  of  the  external  carotid  at  their   origin,    as  the 


Hypoglossal  nerve 
Occipital  artery 

Ext" nal  maxillary  artery  — , 
Common  facial  vein  — " 
Submaxillary  gland 

Lingual  artery 

Scalenus  anticus  muscle 

Thvroid  gland 

Inferior  thj  roid  artery 

Becurrent  laryngeal  nerve 


Descending  branch  of  the 
hypoglossal 


Zygomatic  arch 


Temporal  artery 

Auriculo-temp'l  nerve 
Temporal  vein 


Internal  jugular  vein 
Sterno-mastoid  muscle 

' j  Descending  branch  of  the 

hypoglossal 

, —  Internal  carotid  artery 
External  carotid  artery 

Omo  h  J  Old  muscle 

Sttrnb-mastoid  muscle 
—    Common  carotid  artery 
—  Phrenic  nerve 


Longus  colli  muscle 

Sterno-hyoid  muscle 

Fig.  34  B. 

superior  thyroid,  the  lingual,  the  external  maxillary,  and  the 
occipital  artery.  The  course  of  these  four  main  branches  is 
sufficiently  characterized  by  their  direction,  downward,  forward, 
upward,  and  backward,  respectively.  For  the  perijDheral  liga- 
ture of  these  vessels  there  are  more  accessible  and  more  reliable 
points. 

38.   Superior  Thyroid  Artery  (Fig.  10)  — The  ligature  of  the 
superior  thyroid  arter}^  is  effected  at  the  tip  of  the  upper  cornu 


88  OPERATIVE    SURGERY. 

of  the  thyroid  gland.  The  incision  chosen  is  thp.t  portion  of  our 
normal  incision  which  passes  from  the  anterior  margin  of  the 
sterno-cleido- mastoid  muscle  to  the  body  of  the  hyoid  bone. 
The  lower  edge  of  the  skin  wound  is  drawn  vigorously  down- 
ward. Where  the  superior  cornu  of  the  thyroid  gland  does  not 
rise  so  high,  it  is  better  to  make  the  transverse  incision  3  cm. 
deeper,  corresponding  to  the  upper  margin  of  the  thyroid  carti- 
lage. The  anterior  branch  of  the  su^rior  thyroid  artery,  in 
cases  of  enlargement  of  the  gland  for  which  alone  this  ligature 
comes  in  question,  can  always  be  felt  on  the  median  anterior 
side  of  the  superior  cornu,  passing  downward  along  the  larynx. 
By  following  this  branch  beyond  the  tip  of  the  upper  cornu  the 
trunk  of  the  artery  is  sure  to  be  found. 

39.  Lingual  Artery  (Fig.  35) . — Ligature  of  the  lingual  artery 
is  of  importance  because  it  supplies  a  more  deeply  seated  organ 
in  which  the  arrest  of  hemorrhage  is  not  always  easy.  Hence 
prophylactic  ligature  is  often  desirable.  The  course  of  the  lin- 
gual artery  is  well  marked,  for  it  passes  toward  the  hyoid  bone, 
with  the  posterior  end  of  whose  large  cornu  it  comes  in  close 
proximity. 

This  point  is  best  for  ligation  because  in  most  persons  the  end 
of  the  large  cornu  of  the  hyoid  bone  can  be  felt  through  the 
skin  and  thus  furnishes  a  definite,  guiding-point  for  incisions. 
We  open  in  the  direction  of  our  normal  incision  from  the  mar- 
gin of  the  sterno-cleido-mastoid  muscle  along  the  large  cornu  of 
the  hyoid  bone  as  far  as  the  body  of  this  bone.  The  incision 
divides  the  skin,  platysma,  and  fascia  as  if  the  large  cornu  of 
the  hyoid  bone  alone  were  to  be  laid  bare.  When  this  is  done 
the  cornu  is  seized  with  a  hook  and  the  bone  drawn  upward ; 
thereby  we  secure  the  great  advantage  that  the  entire  field  of 
operation  is  made  more  superficial.  At  the  thickened  posterior 
end  of  the  cornu  the  fibres  of  the  hyo-glossus  muscle  ascend 
vertically  in  a  characteristic  manner.  Care  is  required  so  that 
close  above  the  club-shaped  end  of  the  cornu  no  more  and  no 


THE  UPPER  LATERAL  CERVICAL  TRIANGLE. 


89 


less  is  divided  than  these  muscuh^r  fibres.  Then  the  artery  ap- 
pears immediately  above  that  extremity.  This  mode  of  Hga- 
ture  we  beheve  to  be  the  most  reliable. 

A  second  method  recommended  for  this  ligature  is  that  over 
the  digastric  muscle.  The  incision  is  made  parallel  to  the  large 
cornu  of  the  hyoid  bone;  extends  through  skin,  platysma,  and 


Temporal  fascia 

Temporal  muscle 
Temporal  artery 

Zygomatic  arch 

Masseter  muscle 


Digastric  muscle 


SubmaxiU'ry  gland 
Lingual  artery 

Hyoglossus  muscle 

Superior  laryngeal  nerve 

Common  carotid  artery 

Platysma 

Omohyoid  muscle 


Auricularis  magnus  nerve 
External  jugular  vein 
Sterno-mastoid  muscle 
Accessory  nerve 
Internal  jugular  vein 
Common  facial  vein 
Hyoglossal  nerve 
Major  cornu  of  the  hyoid  bone 


Descending  branch  of  the 
hypoglossal  nerve 
Vagus  nerve 

Common  jugiilar  vein 
—  Stemo-niastoid  muscle 


•'•-'//</: 


Fia.  35. 


fascia ;  and  the  lower  margin  of  the  submaxillary  salivary  gland 
with  the  anterior  facial  vein  is  drawn  forward.  In  the  angle 
formed  by  the  upper  margin  of  the  digastric  and  the  stylo-hyoid 
muscles  with  the  posterior  margin  of  the  mylo-hyoid,  the  artery 
lies  under  the  ascending  fibres  of  the  hyo-glossas  muscle.  On 
the  external  surface  of  this  latter  muscle  lies  the  hypoglossal 
nerve  and  often  one  of  the  lingual  veins. 


90  OPEKATIVE   SURGERY. 

All  hemorrhages  about  the  head,  excepting  those  which  are 
intracranial  and  within  the  orbit,  can  be  arrested  by  ligation  of 
the  external  carotid,  which  is  a  reliable  and  safe  operation. 
The  common  carotid  should  never  be  ligated  in  place  of  the  ex- 
ternal, because  it  is  impossible  to  foresee  whether  a  permanent 
disturbance  of  the  cerebral  circulation  (especially  in  persons  of 
advanced  age)  will  not  ensue  in  consequence  thereof. 

40.  In  the  case  of  intracranial  hemorrhages  ligation  of  the 
internal  carotid  (Fig.  11)  is  to  be  preferred  to  that  of  the  com- 
mon carotid  because  the  collateral  circulation  from  the  angular 
artery  into  the  branches  of  the  ophthalmic  artery  is  preserved. 
The  ligation  equals  that  of  the  external  carotid,  but  upward 
between  both  vessels  pass  the  stylo-glossus  and  stylo -pharyngeus, 
and  the  deep  fascia  with  the  stylo -maxillary  ligament. 

During  pharyngeal  operations  in  which  profuse  hemorrhages 
may  suddenly  occur,  and  occasionally  even  during  tonsilloto- 
mies, it  is  important  to  be  certain  as  to  whether  a  hemorrhage 
comes  from  the  internal  carotid  or  from  branches  of  the  exter- 
nal carotid  (pharyngeal  and  tonsillary  artery).  In  tonsillotomy 
injury  to  the  internal  carotid  is  not  the  one  to  be  most  feared, 
although  the  artery  is  felt  pulsating  behind  the  gland ;  for  in 
the  region  of  the  tonsil  the  artery  is  separated  from  the  pharyn- 
geal wall  by  the  stylo-glossus  and  stylo -pharyngeal  muscles. 
But  injury  may  be  inflicted  on  the  pharyngeal  artery  and  the 
ascending  palatine  with  its  tonsillary  branch  (Zuckerkandl) . 

41.  The  exposure  of  the  hypoglossal  nerve  coincides  with 
that  of  the  external  carotid  artery  which  it  surrounds  from 
without,  and  in  its  anterior  portion  it  coincides  with  that  of 
the  lingual  artery.  But  the  nerve  lies  on  the  external  surface 
of  the  hyo-glossus  muscle,  the  artery  on  its  internal  surface. 

42.  If  the  submaxillary  salivary  gland  is  turned  out,  the 
posterior  fibres  of  the  mylo-hyoid  muscle  are  incised,  and  we 
work  upward  along  the  outer  surface  of  the  hyo-glossus  muscle 
toward  the  mucosa  of  the  floor  of  the  mouth,  it  is  possible  to 


THE  UPPER  LATERAL  CERVICAL  TRIANGLE.  91 

expose  the  lingual  nerve,  though  it  lies  very  deep,  from  the 
neck  through  our  normal  incision  (Fig.  10). 

43.  Superior  Larymjeal  Nerve  (Fig.  35). — This  branch  of 
the  vagus,  which  furnishes  the  main  sensory  supply  of  the 
larynx,  is  rendered  visible  at  the  lower  edge  of  the  skin  when 
the  hyoid  portion  of  our  normal  incision  is  drawn  down.  It 
passes  forward  in  the  depth  behind  the  external  carotid  (where 
the  external  maxillary  artery  is  given  off),  parallel  to  the  large 
cornu  of  the  hyoid  bone,  above  the  pharyngo-laryngeal  muscle 
oil  the  outer  surface  of  the  hyo-thyroid  membrane,  and  disap- 
pears under  the  posterior  margin  of  the  thyro-hyoid  muscle.  It 
is  exceedingly  important  to  bear  the  course  of  this  nerve  in. 
mind,  for  its  injury  causes  insensibility  of  the  larynx,  and 
where  this  follows  operations  on  the  pharynx  and  mouth  the 
patients  are  very  liable  to  die  of  foreign-body  pneumonia. 

rttt.  Ligation  of  the  Internal  and  Connnon  Jugular  Vein 
(Figs.  11  and  35). — This  operation  is  the  same  as  that  for  liga- 
tion of  the  external  and  common  carotid.  The  vessel  lies  on 
the  outer  side  of  the  internal  carotid.  Aside  from  hemorrhages, 
the  ligation  is  of  special  importance  in  infectious  thrombosis  in 
the  afferent  region  of  the  vein.  For  instance,  when  an  otitis 
media  and  mastoidea  extends  to  the  bone,  thrombi  may  form  in 
the  transverse  sinus.  When  such  thrombi  break  up,  embolic 
pyaemia  ensues.  Ligation  of  the  internal  or  common  jugular 
vein  is  to  prevent  this. 

45.  The  spinal  accessory  nerve  (Figs.  10  and  35)  jDasses  down- 
ward dorsad  of  the  large  vessels,  giving  off  branches  to  the  sterno- 
cleido-mastoid  and  trapezius  muscles.  In  spasm  of  these  mus- 
cles stretching  of  this  nerve  is  indicated.  Its  preservation  in 
operations  about  the  uj^per  end  of  the  sterno-cleido-mastoid  is 
still  more  important,  especially  during  the  excision .  of  glands 
frequently  performed  at  this  point.  For  exposing  the  nerve  we 
use  the  mastoid  portion  of  our  normal  incision,  and  after  the 
external  jugular  vein  and  the  large  auricular  nerve  have  been 


92  OPEEATIVE   SURGERY. 

lifted  off,  the  muscle  is  drawn  back.  The  course  of  the  nerve 
is  well  marked:  from  the  distinctly  palpable  anterior  circum- 
ference of  the  transverse  process  of  the  atlas  it  runs  obliquely 
downward  and  backward  under  the  anterior  margin  of  the 
sterno-cleido-mastoid  muscle.  The  occipital  artery  passes  back- 
ward over  it.  Above,  the  nerve  is  covered  by  the  digastric 
muscle.  In  front  the  sterno-cleido-mastoid  artery  (from  the 
external  carotid)  runs  parallel  to  the  nerve. 

46.  Lateral  Pharyngotomy . — The  above-described  normal 
incision  forms  the  foundation  for  all  operations  intended  to  lay 
bare  from  without  the  lateral  pharyngeal  region  with  the  tonsil 
and  the  base  of  the  tongue. 

The  incision  for  the  lateral  opening  of  the  pharynx,  which 
permits  full  inspection  of  the  lateral  margin  of  the  tongue  as 
far  as  the  epiglottis,  and  the  lateral  pharyngeal  wall  with  the 
entire  retro-pharyngeal  space,  corresponds  to  our  complete  nor- 
mal incision  for  the  upper  cervical  triangle  (Fig.  24).  The 
large  auricular  nerve  and  the  external  jugular  vein  must  occa- 
sionally be  severed  if  the  posterior  portion  of  the  incision  is  to 
be  made  fully  accessible. 

After  dividing  the  skin,  platysma,  and  fascia  the  infra- 
mandibular  region  is  exposed ;  but  further  progress  toward  the 
floor  of  the  mouth  and  the  pharyngeal  wall  is  interfered  with 
by  the  vessels  which  pass  from  below  toward  the  outer  surface 
of  the  maxilla.  These  hindrances  are :  the  anterior  facial  vein 
on  the  external  surface  of  the  posterior  belly  of  the  digastric, 
the  external  maxillary  artery  under  the  maxillary  gland,  and 
finally  the  latter  gland  itself.  The  vessels  named  must  be 
doubly  ligated  and  cut ;  the  submaxillary  gland  is  lifted  out  and 
turned  upward  or  extirpated.  It  may  be  useful  to  ligate  also 
the  lingual,  pharyngeal,  and  palatine  arteries  at  their  origin, 
or  else  to  ligate  the  external  carotid.  This  will  make  it  possible 
to  draw  the  large  cervical  vessels  with  the  vagus  and  spinal  acces- 
sory nerves  backward,  and  the  arch  of  the  hypoglossal  nerve  up- 


THE  UPPER  LATERAL  CERVICAL  TRIANGLE.  03 

ward.  The  superior  laryngeal  nerve  and  the  superior  thyroid 
artery  remain  under  the  lower  wound  margin.  We  must  save 
all  we  can  of  the  presenting  muscles  in  the  interest  of  the 
mechanism  of  deglutition,  and  therefore  proceed  along  the  in- 
ternal surface  of  the  maxilla  and  the  internal  pterygoid  muscle 
toward  the  mucous  membrane.  If  adhesions  or  the  limitation 
of  the  field  force  us  to  divide  the  muscles,  we  must  do  so  in  a 
way  to  preserve  the  innervation  of  the  intact  muscles.  For  in- 
stance, the  posterior  belly  of  the  digastric  and  stylo-hyoid  are 
severed  as  close  as  possible  to  the  hyoid  bone,  being  supplied 
from  behind  (through  the  facial  nerve) ;  the  stylo-glossus,  for 
the  same  reason,  is  cut  near  the  tongue  so  as  to  preserve  the 
lingual  and  glosso- pharyngeal  nerves  which  adjoin  it.  The 
stylo-pharyngeus  is  divided  near  its  attachment  to  the  pharynx; 
the  hyo-glossus  and  myo-hyoid  (supplied  from  above  through 
the  hypoglossal  nerve),  at  their  attachment  to  the  hyoid  bone, 
so  far  as  may  be  necessary.  Now  the  pharyngeal  wall  is  ex- 
posed, limited  above  by  the  cephalo -pharyngeal,  below  by  the 
laryngo- pharyngeal  muscle.  Of  course,  adhesions  would  neces- 
sitate cutting  the  lingual  and  glosso-pharyngeal  nerves. 

The  upper  part  of  the  pharynx,  however,  can  only  be  ren- 
dered completely  accessible  to  the  eye  by  adding  the  above- 
mentioned  osteoplastic  resection  of  the  lower  maxilla;  or,  to 
express  it  more  correctly,  the  oblique  division  of  the  maxilla  in 
a  direction  from  behind  inward  and  above,  to  in  front  outward 
and  below,  at  the  anterior  margin  of  the  masseter  muscle ;  after 
which  the  ascending  ramus  of  the  jaw  is  vigorously  drawn 
upward  and  the  horizontal  ramus  forward. 

Should  the  new -formation  in  the  tongue  and  pharynx 
have  extended  to  the  transition  fold  between  the  upper  and 
lower  maxilla,  it  will  be  best  to  saw  through  the  jawbone  at  the 
above-named  point,  if  necessarj'"  detach  the  soft  parts  (the  mas- 
seter externally,  the  internal  pterygoid  internally)  from  the 
bone  by  twisting  the  joint  capsule  and  the  external  pterygoid 


94  OPERATIVE   SURGERY. 

muscle,  and  to  exarticulate  and  remove  the  ascending  ramus  of 
the  maxilla.  This  will  most  certainly  prevent  subsequent  anky- 
losis of  the  jaw.  In  this  operation  as  in  the  above-described 
resection  the  inferior  alveolar  nerve  and  artery  are  cut  and  the 
latter  ligated. 

If  the  lowest  part  of  the  pharynx  behind  the  larynx  is  to  be 
exposed,  the  muscles  of  the  tongue  and  pharynx  with  their 
nerves  remain  intact,  as  well  as  the  branches  of  the  external 
carotid.  The  pharynx  is  opened  below  the  superior  laryngeal 
nerve,  between  the  latter  and  the  superior  thyroid  artery 
(which  may  have  to  be  cut),  the  incision  reaching  from  the 
larynx  upward  to  the  point  where  the  descending  ramus  of 
the  hypoglossal  nerve  is  given  off,  at  the  anterior  margin  of  the 
carotid.  In  order  to  expose  the  lowest  part  of  the  pharynx  it  is 
often  necessary  to  add  to  the  normal  incision  (which  is  then  to 
be  shortened  behind  correspondingly)  a  longitudinal  incision 
downward  along  the  anterior  margin  of  the  sterno-cleido- 
mastoid  muscle  (Fig.  22). 

47.  Median  or  Subhyoid  Pharyngotomy  (Fig.  36). — To  ex- 
pose the  entrance  of  the  larynx  when  disease  is  limited  to  this 
region  it  is  best  to  proceed  from  in  front.  Transverse  incision 
upon  the  body  of  the  hyoid  bone  and  the  anterior  portion  of  the 
large  cornu  of  this  bone,  extending  from  one  side  to  the  other 
through  the  skin  and  muscular  fibres  of  the  platysma,  thus 
exposing  the  hyoid  bone.  Vertical  connections  of  the  subcuta- 
neous veins  are  ligated.  The  hyoid  artery  and  vein  run  upon 
the  bone  of  the  same  name  and  must  likewise  be  ligated.  The 
incision  divides  the  attachments  of  the  muscles  to  the  hyoid 
bone  as  far  as  necessary,  at  first  the  sterno-hyoid  and  omo-hyoid 
and  laterally  the  thyro-hyoids.  It  is  desirable  to  preserve  some 
of  the  fibres  of  these  muscles.  The  hyo-thyroid  membrane  is 
now  laid  bare.  After  dividing  it  we  work  up  under  the  hyoid 
bone  in  order  to  open  the  mucous  membrane  between  the  base 
of  the  tongue  and  the  epiglottis.     We  object  to  making  the 


THE  UPPER  LATERAL  CERVICAL  TRIANGLE. 


95 


/!t^' 


Sfubhyoid  pliai-yngotoiiiy 


Pectoralis  major  muscle 
Clavicle 
Sul)cla\  lan  veiu  ,    | 
Anterior  thoi  acic  iifrv  i^-,  i    ' 
:Mib.jla\ian  .u  ttrv 
C.-pli.ilii   veia 
Thoracicoacroinml  .11  ter>  I 
Deltoid  mu-cl 
Pectoralis  iiiinoi- 
aiuscle 


Hyoid  bone 
Stemo-hyoid  muscle 

Thyro-hyoid  muscle 
Epiglottis 
Tfiyroifl  cartilage 
TI\o  thjioid  iiiftubrane 
bterno  thjroid  muscle 
Steino  hjoid  muscle 
Median  jugulai  veiu 
Innominate  ai  leiy 
End  of  the  clavicle 
Left  innominate  vein 

Infisura  stHrni  vein 
^otch  of  tilt  bteriium 
%?j   ^3>^       \     bteino 
'l  m'stoidm. 


Pectoralis  major  m 

Exfl  intercostal  m  .^ 
<Ligament.  coruscaus) 
Inti  intercosral  lu  —  • 
Pleura — : 
External  obliquus  i      -"    , 
abdominis  muscle  i  ~^^^0 
Rib  -^-'  /' 
Periosteum  -^?  '^- 
Exfl  intercostal  m  r^'f 
^/' 

Aponeurosis  of  the 

external  oblique    \  ^ 
Rectus  aljJorniuis  m  -- 
Intereos.  nerve  &  \  essels  ^-' 
Internal  obliquus  ab  i 
dominis  muscle       i 
Gall  blidder 
External  ol)liquu.->  ab 
dominis  umscle 

Ascending  col  n 
Small  intestii . 


■Circjmflexa  il    arter\ 


.JW 


Ti  ans^  ei  ^us  abdominis 
./jj  I     muscle  with  fascia 
,#  Peritoneum 
-=a^i-  Liver 
—  Omentum 


\  Fascia  of  the  ob- 
I  liquus  externusm. 
1  P'a^cia  of  the  inter- 
I  nal  oblique  muscle 
Rectus  abdominis  m. 


Ti  ansversalis  fascia 
J  Inferior  epigastric 
I  artery 


96  OPERATIVE   SURGERY. 

division  away  from  the  hyoid  bone,  owing  to  the  course  of  the 
superior  laryngeal  nerve  which,  piercing  the  thyro-hyoid  mem- 
brane, enters  the  larynx.  If  its  branches  are  cut  the  larynx  is 
rendered  insensitive  and  this  gives  rise  to  the  entrance  of  food 
particles,  mucus,  and  wound  secretions  into  the  larynx.  Such 
substances  are  not  removed  by  reflex  cough  and  dangerous 
foreign-body  pneumonia  is  the  result. 

The  epiglottis  can  now  be  seized  with  a  sharp  hook  and 
drawn  forward,  thus  affording  a  very  good  view  of  the  entrance 
of  the  larynx,  especially  the  region  of  the  arytenoid  cartilages 
which  is  subject  to  many  diseases  (tuberculosis,  cancer).  In 
order  to  permit  undisturbed  operation  we  must,  as  in  laryng- 
otomies,  reduce  the  irritability  of  the  mucous  membrane  by 
painting  it  with  a  ten-per-cent  cocaine  solution. 

The  described  operation,  which  was  introduced  by  von  Lan- 
genbeck,  is  to  be  highly  recommended  for  the  entrance  of  the 
larynx  and  especially  the  septum  between  the  latter  and  the 
pharynx,  since  it  is  not  followed  by  incidental  functional  dis- 
turbances. 

In  the  after-treatment  of  the  wound  made  by  pharyngotomy 
we  must  bear  in  mind  that  we  have  to  deal  with  tissues  infected 
ab  initio,  for  the  pharynx  cannot  be  completely  disinfected. 
For  this  reason  it  is  advisable,  in -the  case  of  ulcerations  and 
ulcerated  tumors,  to  make  the  resection  in  two  steps :  first  the 
dissection  as  far  as  the  pharynx,  then  the  wound  is  allowed  to 
granulate  by  filling  it  with  aseptic  gauze  and  keeping  it  well 
open.  Not  until  three  or  four  days  later  is  the  pharynx  opened 
and  the  tumor  or  ulcer  removed,  best  with  the  thermo-cautery. 
Where  operation  in  two  steps  is  not  feasible  and  the  whole  must 
be  performed  in  one  sitting,  the  main  thing  is  an  open  antiseptic 
wound  treatment,  i.e.,  the  wound  is  filled  with  carbolic  gauze, 
each  time  freshly  prepared  bj^  immersion  in  five-per-cent  car- 
bolic solution  and  expression.  The  gauze  is  changed  every  two 
hours,  when  necrotic  points  are  painted  with  tincture  of  iodine, 


THE   ANTERIOR   CERVICAL   TRIANGLE.  97 

or  powdered  iodoform  or  bismuth  is  rubbed  into  them.  Should 
the  effect  of  the  carboHc  acid  be  too  strong,  thymol  gauze  tam- 
pons are  substituted.  These  must  likewise  be  each  time  freshly 
prepared  by  immersion  in  0.1-per-cent  thymol  solution  and  ex- 
pression. 

It  is  self-evident  that  under  favorable  conditions — that  is, 
when  the  wound  is  small  and  an  exact  suture  can  be  applied — 
the  attempt  at  healing  by  first  intention  may  occasionally  be 
justified  in  pharyngotomy,  the  wound  surface  in  the  pharynx 
having  been  thoroughly  dusted  with  iodoform.  Every  tam- 
ponade of  the  pharynx  and  the  entrance  of  the  larynx  presup- 
poses a  tracheotomy  which  is  indicated  even  for  the  sake  of 
securing  a  quiet  operation ;  it  had  best  precede  the  main  opera- 
tion by  several  days. 

H.  The  Anterior  Cervical  Triangle.' 

If  w^e  are  to  enter  deeply  between  the  contents  of  the  neck 
and  the  sterno-cleido-mastoid  muscle,  transverse  incisions  cor- 
resj)onding  to  the  cleavage  lines  of  the  skin  do  not  always 
suffice,  and  we  are  often  forced  to  make  longitudinal  incisions, 
either  median  or  lateral  along  the  sterno-cleido-mastoid  muscle. 

48.  Common  Carotid  Artery  (Figs.  2-i  and  25). — The  com- 
mon carotid  ascends  vertically  in  the  shortest  direction  from  the 
chest  to  the  head.  The  incision  exposing  it,  therefore,  lies  ver- 
tically and  crosses  the  anterior  margin  of  the  sterno-cleido- 
mastoid  muscle  or  the  line  corresponding  to  it  from  the  angle 
of  the  jaw  to  the  sterno-clavicular  articulation.  The  artery  can 
also  be  exposed  very  readily  by  a  transverse  incision,  whose 
centre  corresponds  to  the  anterior  margin  of  the  sterno-cleido- 
mastoid,  made  at  the  height  of  the  cricoid  cartilage.  This  in- 
cision, corresponding   to   the   cleavage  line   of  the  skin,  leaves 

'  The  limits  of  this  triangle  are  the  vi]iper  margin  of  the  thyroid  cartilage  and 
the  anterior  margins  of  the  sterno  cleido-mastoid  muscles  as  far  as  the  jugulum. 

7 


98  OPERATIVE   SURGERY. 

a  better  cicatrix.  The  artery  can  be  felt  throughout  the  entire 
neck  alongside  of  the  trachea  and  oesophagus  and  may  be  com- 
pressed with  certainty  against  the  vertebral  column,  best  at  the 
height  of  the  cricoid  cartilage.  By  its  side  we  feel  the  markedly 
projecting  transverse  process  of  the  sixth  cervical  vertebra,  the 
so-called  tuberculum  caroticum.  Now  and  then  compression  of 
the  carotid  will  incidentally  cause  pressure  symptoms  on  the  part 
of  the  vagus  nerve,  slowing  of  the  pulse,  and  dyspnoea  to  a  feeling 
of  syncope.  The  preferred  point  for  ligating  the  artery  is  like- 
wise at  the  height  of  the  cricoid  cartilage.  This  cartilage  can 
nearly  always  be  distinctly  felt.  After  dividing  the  skin  and 
platysma,  the  transverse  subcutaneous  colli  nerve  appears,  pass- 
ing forward  over  the  sterno-cleido-mastoid  muscle  from  its  poste- 
rior margin.  It  is  cut  (preserved  in  the  transverse  incision)  and 
the  fascia  divided  so  that  the  body  of  the  sterno-cleido  muscle 
is  laid  bare.  Its  anterior  margin  is  drawn  outward  with  a 
blunt  hook.  Under  this  margin  the  omo-hyoid  muscle  is  seen 
passing  upward  and  somewhat  medially.  The  artery  is  ap- 
proached through  the  angle,  open  above,  between  the  two  mus- 
cles named.  The  vessel  is  still  covered  by  the  second  fascia 
which  forms  its  sheath  at  the  same  time.  After  this  is  divided 
the  artery  is  exposed.  The  descending  branch  of  the  hypo- 
glossal, the  motor  nerve  for  the  muscles  rising  to  the  larynx, 
passes  down  on  the  sheath  of  the  vessel.  The  nerve  is  carefully 
drawn  to  the  median  side.  The  greatest  caution  is  required 
lest  the  vagus  nerve,  which  lies  close  to  the  posterior  surface  of 
the  artery,  be  included  in  the  ligature.  The  common  jugular 
vein  lies  outward  and  the  sympathetic  backward  of  the  artery. 

49.  Ligation  of  the  Common  Jugular  Vein  (Figs.  S-i  and  25). 
— At  the  same  point  the  common  jugular  vein  can  be  ligated. 
It  lies  on  the  antero-lateral  side  of  the  common  carotid  artery. 
The  ligation  is  indicated,  aside  from  hemorrhages,  when  throm- 
boses have  formed  in  the  afferent  field,  especially  in  the  trans- 
verse sinus  by  extension  of  infectious  inflammations  from  the 


THE   ANTERIOR   CERVICAL   TRIANGLE.  99 

ear.  The  vein  is  very  frequently  ligated  when  it  is  adherent  to 
tumors  such  as  mahgnant  struma,  carcinoma  and  sarcoma  of 
lymphatic  glands. 

50.  At  the  same  point  and  for  the  last-named  reasons  resec- 
tion of  the  vagus  nerve  (Fig.  25)  may  become  necessary.  Uni- 
lateral division  of  this  nerve  can  be  performed  without  danger 
to  life,  even  without  any  disturbance  of  the  patient. 

51.  Ligation  of  the  Inferior  Thyroid  and  the  Vertebral  Ar- 
tery (see  Figs.  37  and  38). — Ligation  of  these  two  large  branches 
of  the  subclavian  artery  is  properly  performed  from  the  same  ver- 
tical incision  which  was  described  for  the  common  carotid,  lat- 
erally from  the  cervical  structures  in  the  anterior  cervical 
triangle,  crossing  the  margin  of  the  sterno-cleido  muscle,  but 
prolonged  as  far  as  the  clavicle. 

We  have  often  ligated  the  thyroid  artery  for  struma  vascu- 
losa  in  recent  years,  since  Wolfler  has  recommended  the  opera- 
tion for  struma  in  general.  A  well-marked  point  for  exposing 
the  vessel  is  where  it  changes  its  upward  direction  to  a  median, 
toward  the  posterior  surface  of  the  thyroid  gland.  Here  the 
horizontal  artery  lies  on  the  median  side  of  the  common  carotid, 
resting  on  the  spinal  column  or  the  longus  colli  muscle.  The 
operation  resembles  that  for  exposing  the  common  carotid  at 
the  lower  part  of  the  neck.  The  skin  and  platysmaare  divided, 
the  anterior  margin  of  the  sterno-cleido-mastoid  muscle  is  laid 
bare  and  drawn  vigorously  outward ;  if  more  room  is  needed  it 
is  incised.  The  common  jugular  vein  and  the  carotid  with  the 
vagus  are  drawn  outward.  At  the  inner  side  of  the  bundle  of 
vessels,  between  this  and  the  margin  of  the  thyroid  gland  or 
the  muscles  covering  it,  the  sterno-hyoid  and  sterno-thyroid,  we 
proceed  toward  the  spinal  column.  Here  the  pulsation  of  the 
artery  is  felt.  The  thyroid  gland  must  be  drawn  in  a  median 
direction  and  lifted  up.  The  artery  is  characterized  by  a  curve 
whose  convexity  is  upward  and  outward,  for  the  ascending 
Tessel  turns  in  a  median  direction  to  the  point  where  the  thyroid 


100 


OPERATIVE   SURGERY, 


gland  and  trachea  join.  The  thyreo-cervical  artery  gives  off, 
besides  the  thyroid  artery,  the  ascending  cervical  and  the  super- 
ficial cervical.  The  operation  must  be  performed  under  careful 
control  and  thorough  arrest  of  hemorrhage,  so  as  to  enable  us, 
on  the  one  hand,  to  preserve  the  inferior  laryngeal  nerve  where 
it  crosses  the  artery ;  for  that  nerve  furnishes  the  chief  motor 


Hypoglossal  nerve 
Occipital  artery 

Ext'nal  maxillary  artery 
Common  facial  vein 
Submaxillary  gland 

Lingual  artery 

Scalenus  anticus  muscle 

Thyroid  gland 

Inferior  thyroid  artery 

Recurrent  laryngeal  nerve 


rc-i 


Descending  branch  of  the 
hypoglossal 


Zygomatic  arch 


Temporal  artery 

Auriculo-temp''l  nerve 
Temporal  vein 


Internal  jugular  vein 
Sterno-mastoid  muscle 
J  DescendiDg  branch  of  the 
(         hypoglossal 
Internal  carotid  artery 
External  carotid  artery 


i-hyoid  muscle 

Sterno-mastoid  muscle 
Common  carotid  artery 
Phrenic  nerve 


Loagus  colli  muscle 

Sterno-hyoid  muscle 


Fig.  37. 


supply  of  the  larynx.  On  the  other  hand  we  must  guard 
against  lesion  of  the  cardiac  branches  of  the  sympathetic  or 
division  of  the  trunk  of  the  'sympathetic  which  occasionally  sur- 
rounds the  artery  with  an  anterior  and  posterior  branch.  When 
the  thyroid  gland  is  enlarged  the  capsule  must  be  divided  and 
the  gland  drawn  in  a  median  direction  with  a  blunt  hook.  At 
the  same  time  the  inferior  accessory  thyroid  vein  should  be 
doubly  ligated  and  cut. 


THE   ANTERIOR   CERVICAL   TRIANGLE.  101 

52.  Vertebral  Artery  (Fig.  38.) — Ligation  is  effected  in  an 
analogous  manner  to  that  for  the  inferior  thyroid ;  it  is  more 
difficult  because  the  artery  lies  still  deeper.  Its  course  is  not 
only  upon  but  within  the  deep  cervical  muscles,  under  the  pre- 
vertebral fascia.  The  main  guiding  point  for  the  artery  is  the 
so-called  tuberculum  caroticum  at  the  transverse  process  of  the 
sixth  cervical  vertebra,  the  most  promi- 
nent portion  of  the  antero-lateral  sur- 
face of  the  cervical  spinal  column.  This 
tubercle  is  also  used  in  ligation  of  the 
carotid,  whence  the  name.  It  is  not  of 
much  importance  in  ligation  of  the  ca- 
rotid, but  is  undoubtedly  so  for  ligation  ^^^  ^  ^ 
of  the  vertebral  artery  which  here  enters 

the  transverse  foramen.  It  would  be  more  appropriate,  there- 
fore, to  name  this  prominence  the  vertebral  tubercle.  The 
artery  ascends  toward  the  lower  surface  of  this  tubercle.  After 
the  sterno-cleido  muscle  with  the  large  cervical  vessels  has  been 
drawn  outward,  and  the  sterno-hyoid  and  sterno-thyroid  in- 
ward, the  prevertebral  fascia  is  divided  above  the  curve  of  the 
inferior  thyroid  artery;  then  the  vertically  ascending  artery, 
which  disappears  above  under  the  vertebral  tubercle,  is  felt  upon 
and  partly  within  the  fibres  of  the  longus  colli  muscle.  In  a 
lateral  direction  lies  the  scalenus  anticus  muscle  and  upon  it  the 
phrenic  nerve.  The  latter  passes  from  the  outer  margin  of  the 
muscle  over  its  anterior  surface  and  enters  the  upper  thoracic 
aperture. 

53.  (Esophagotomy  (Fig.  10). — The  oesophagus  is  opened  in 
the  anterior  cervical  triangle  from  the  left  side,  where  it  pro- 
jects beyond  the  trachea.  If  it  is  to  be  exposed  on  account  of  a 
new-formation  or  a  foreign  bod}'',  the  incision  is  made  exactly 
like  that  for  ligation  of  the  common  carotid  and  the  inferior 


'  This  figure  represents  the  incision  for  the  inferior  thyi'oid  artery  shown  in 
Fig.  37,  but  on  a  larger  scale. 


102  OPERATIVE    SURGERY. 

thyroid  artery,  but  it  should  be  longer.  After  withdrawal  of 
the  sterno-cleido  muscle  and  the  large  cervical  vessels  the  inferior 
thyroid  artery  must  be  doubly  ligated,  and  the  thyroid  gland  lifted 
in  a  median  direction  together  with  the  sterno-hyoid  and  sterno- 
thyroid muscles  covering  it.  The  capsule  of  the  gland,  forming 
a  part  of  the  deep  fascia  which  adheres  laterally  to  the  sheath 
of  the  large  cervical  vessels,  must  be  divided.  The  oesophagus 
becomes  accessible  only  after  dividing  the  deep  fascia.  Great 
care  is  to  be  taken  to  preserve  the  recurrent  laryngeal  nerve 
which  runs  upward  in  a  groove  between  the  trachea  and  oeso- 
phagus; for  this  reason  the  oesophagus  must  be  opened  quite 
laterally  or  latero-posteriorly.  Its  opening  is  more  difficult 
when  the  tube  is  collapsed,  hence  the  oesophagus  is  first  dilated 
by  the  introduction  of  a  sound  or  olive-tipped  bougie. 

54.  Retro-CBSophageal  Space. — The  same  operation  gives  ac- 
cess to  retro-pharyngeal  and  retro-oesophageal  abscesses.  These 
abscesses,  which  are  largely  due  to  tubercular  disease  of  the 
vertebral  column  and  the  glands,  ma}^  endanger  life  not  only  by 
closing  the  entrance  of  the  larynx,  but  by  their  rupture  causing 
sudden  suffocation.  Opening  them  from  without  instead  of 
from  within  has  the  advantage  that  no  communication  is  estab- 
lished with  the  lumen  of  the  pharynx  and  oesophagus,  thus  per- 
mitting a  relatively  aseptic  course. - 

Laryngotomy  and  Tracheotomy. — Median  incisions  in  the 
anterior  cervical  triangle  are  among  the  most  frequent  opera- 
tions the  surgeon  is  called  upon  to  perform  for  the  opening  of 
the  larnyx  and  trachea. 

55.  Tracheotomy  (Fig.  39.) — In  the  great  majority  of  cases 
in  which  we  are  forced  to  perform  this  operation  very  rapidly, 
crico-tracheotomy  is  the  safest  and  least  bloody. 

The  upper  tracheal  rings  are  covered  by  the  isthmus  of  the 
thyroid  gland,  which  is  often  rather  thick.  At  its  upper  and 
lower  margin  the  communicating  veins  run  as  stout  transverse 
branches  between  the  thyroid  veins.     Twigs  are  given  off  by 


THE    ANTERIOR   CERVICAL   TRIANGLE. 


103 


them  and  the  anterior  branch  of  the  superior  thyroid  artery  to 
the  pyramidal  process  when  present,  so  that  even  arterial  vessels 
may  cross  the  middle  line  at  the  upper  end  of  the  isthmus.  At 
the  posterior  surface  of  the  isthmus  runs  an  inferior  laryngeal 
branch  from  the  inferior  thyroid  artery  below,  and  beneath  the 
isthmus  we  constantly  find  the  thick  inferior  venae  thyreoidese 


Cricoid  cartilage 
Sterno-hyoid  muscle 


f/1 


Thyroid  isthmus 
Sterno-thyroid  muscle 
Pretracheal  fascia 


Fig.  39.— Tracheotomy,  Bose's  Method. 


rising  vertically  on  both  sides  of  the  median  line;  occasionally 
there  is  also  an  inferior  arteria  thyi-eoidea.  All  these  vessels  can 
be  spared  in  performing  crico-tracheotomy.  The  skin  and 
superficial  fascia  are  divided,  and  the  margin  of  the  sterno- 
thyroid muscle  is  drawn  uj)ward  with  blunt  hooks.  At  first  the 
incision  is  directed  only  against  the  anterior  circumference  of 
the  cricoid  cartilage  which  can  always  be  felt,  and  the  cartilage 


104  OPERATIVE    SUBGERY. 

is  entireh^  exposed.  The  cricoid  artery  on  the  crico-thyroid 
hgament  is  preserved.  After  the  cartilage  is  laid  bare  the  deep 
fascia  which  fastens  the  thyroid  gland  to  the  anterior  surface  of 
the  cricoid  cartilage  is  detached  from  the  inferior  edge  of  the 
latter.  By  entering  w^ith  a  blunt  instrument  the  upper  tracheal 
rings  can  all  be  laid  bare  without  cutting,  by  lifting  the  fascia 
with  the  thyroid  isthmus  and  all  the  vessels  in  its  region  down- 
ward from  the  bared  trachea  (Fig.  39). 

If  crico-tracheotomy  does  not  afford  sufficient  room  or  it  is 
desired  to  make  the  tracheal  wound  farther  from  the  larynx, 
the  cutaneous  incision  must  be  prolonged  downward  and  the 
fascia  between  the  sternal  muscles  below  the  isthmus  divided 
exactly  in  the  median  line.  The  inferior  venae  thyreoidesB  always 
remain  to  the  right  and  left,  as  they  pass  vertically  downward. 
The  deep  fascia  having  been  divided  without  cutting,  we  come 
upon  the  trachea  and  may  open  it  below  the  isthmus  (inferior 
tracheotomy),  or  else  we  may  introduce  an  aneurism  needle  be- 
tween the  trachea  and  the  isthmus  which  latter  has  been  bluntly 
detached  from  above  and  below.  Then  the  isthmus  is  firmly 
ligated  with  strong  thread  to  the  right  and  left  of  the  median 
line  and  divided.  This  mode  is  preferable  where  the  trachea  is 
to  be  adequately  exposed. 

Where  such  an  operation  is  to  precede  a  subsequent  laryn- 
gotomy  or  laryngectomy,  inferior  tracheotomy  is  to  be  preferred, 
as  it  leaves  the  field  free  for  the  second  operation.  Wherever 
possible  such  preliminary  tracheotomies  should  precede  the  main 
operation  a  number  of  days. 

56.  Laryngotomy  and  Laryngectomy. — There  is  an  absolute 
indication  for  opening  the  larynx  in  the  case  of  intra-laryngeal 
malignant  tumors ;  the  operation  may  become  necessary  in  rela- 
tively benign  tumors  such  as  papilloma  of  the  larynx,  ulcers, 
infectious  diseases,  and  tuberculosis  of  the  larynx.  Median  ex- 
posure of  the  larynx  is  comparatively  a  simple  operation.  The 
incision  passes  downward  in  the  median  line  from  the  hyoid 


THE   ANTERIOR   CERVICAL   TRIANGLE.  105 

bone  to  the  upper  part  of  the  trachea.  This  causes  injury  of 
some  vessels:  the  hyoid  artery  (branch  of  the  lingual)  at  the 
hyoid  bone;  the  crico-thyroid  artery  (branch  of  the  superior 
thyroid)  on  the  crico-thyroid  membrane;  a  transverse  branch 
of  the  superior  thyroid  passing  to  the  pyramidal  process  of  the 
thyroid  gland ;  also  numerous  veins  and  transverse  connections 
of  the  venae  median£e  colli  and  deeper  veins.  All  these  vessels 
must  be  ligated.  After  dividing  the  skin  and  fascia,  the  mus- 
cles passing  from  the  sternum  to  the  larynx  and  hyoid  bone  are 
drawn  aside.  The  median  hyo-thyroid  membrane  is  divided 
above  the  thyroid  notch,  and  the  perichondrium  of  the  carti- 
laginous plates  of  the  thyroid  inferiorly.  Now  a  hollow  sound 
can  be  passed  beneath  the  anterior  edge  of  the  thyroid  cartilage 
and  sever  it,  or  it  may  be  freely  divided  from  without  and  the 
plates  drawn  asunder  with  sharp  double  tenacula  before  the 
mucous  membrane  is  cut. 

It  must  be  laid  down  as  a  rule  that  several  days  before  this 
operation  it  should  be  preceded  by  an  inferior  tracheotomy,  so 
as  to  secure  perfectly  free  respiration  during  and  after  the  oper- 
ation and  in  order  that  the  entry  of  blood  and  mucus  into  the 
air  passages  may  be  positively  prevented  by  the  insertion  from 
above  of  soft  little  sponges.  Instead  of  tamponing  simply 
through  the  laryngotomy  wound  above  the  tracheal  canula,  the 
tamponade  can  also  be  effected  from  the  tracheotomy  wound  by 
tying  a  flat  soft  sponge  like  a  diaphragm  to  the  lower  end  of  the 
tracheotomy  canula.  To  obtain  an  unobstructed  view  into  the 
interior  of  the  larynx  we  require  complete  anaesthesia  during 
which  the  cough  reflex  is  inhibited.  It  is  best  to  use  besides 
chloroform  a  local  application  of  a  ten-per-cent  cocaine  solution. 
By  this  means  malignant  neoplasms  can  be  thoroughly  inspected 
and  extirpated.  Should  more  room  be  needed  the  epiglottis  can 
be  divided  above.  For  exact  coaptation  of  the  plates  of  the 
thyroid  cartilage  the  cricoid  cartilage  forms  a  good  support,  pro- 
vided it  can  be  spared. 


106  OPERATIVE   SURGERY. 

57.  Laryngectomy. — Where  the  entire  larynx  is  diseased,  a 
transverse  incision  along  the  hyoid  bone  is  added  to  the  longi- 
tudinal incision  for  the  purpose  of  laryngectomy.  This  addi- 
tional incision  is  like  that  for  subhyoid  pharyngotomy.  A  tra- 
cheotomy a  number  of  days  before  this  operation  is  particularly 
indicated.  Through  the  longitudinal  incision  the  anterior  sur- 
face of  the  larynx  is  laid  bare  and  the  sterno-hyoid  and  thyro- 
hyoid muscles  are  severed  close  to  the  hyoid  bone.  Then  the 
hyo-thyroid  membrane  which  is  attached  under  the  hyoid  bone, 
especially  its  strong  median  ligament,  is  divided  along  with  the 
mucosa  beneath,  and  the  epiglottis  is  drawn  out  with  a  stout 
hook.  The  latter  organ  is  divided  close  to  the  diseased  point ; 
then  the  morbid  portion  is  circumscribed  above  with  the  knife. 
Generally  the  thyroid  cartilage  is  now  divided,  eventually  also 
the  cricoid  cartilage  and  a  portion  of  the  trachea,  so  as  to  fur- 
nish a  clear  insight  into  the  extent  of  the  disease ;  but  this  in- 
formation can  be  gained  also  by  introducing  the  finger.  When 
a  neoplasm  completely  fills  the  larynx  the  mucous  membrane  at 
its  limit  toward  the  pharynx  is  divided,  and  likewise  forward 
toward  the  epiglottis.  If  we  have  operated  in  the  median  line, 
the  mucous  membrane  will  also  be  exactly  divided  along  the 
lower  limit  in  the  larynx  and  in  the  trachea.  Not  until  then 
is  the  outer  surface  of  the  larynx  laid  bare.  As  far  as  possible 
the  muscles  are  preserved  which  cover  the  lateral  and  anterior 
surface  of  the  larynx  (the  sterno-thyroid  and  hyo-thyroid).  If 
the  muscles  are  diseased  they  are  removed.  The  cartilages  are 
exposed  and  as  far  as  they  adjoin  the  neoplasm  directly  they 
are  removed,  in  total  disease  over  the  entire  chxumference.  On 
the  posterior  surface  of  the  cricoid  cartilage  the  oesophageal 
mucosa  is  preserved  if  it  is  healthy  and  movable.  Thus  we 
reach  the  lower  limit  of  the  disease  and  make  a  transverse 
division  in  healthy  tissue,  whether  it  be  the  trachea  or  the 
cricoid  cartilage. 

The  anterior  pharyngeal  and  oesophageal  wall  is  sutured  up- 


THE   ANTERIOR   CERVICAL   TRIANfJLE.  107 

ward  as  far  as  possible  in  order  to  restore  the  septum  between 
the  air  and  food  passages. 

The  after-treatment  is  the  same  as  in  pharyngotomy. 

58.  The  Lntoininate  Artery  (Fig.  oG). — This  artery  is  the 
one  nearest  the  heart,  which  is  accessible  to  ligation ;  it  is  al- 
ways a  grave  operation,  in  view  of  secondary  hemorrhages.  As 
a  rule,  therefore,  we  ligate  at  the  same  time  the  main  branches 
which  carry  the  blood  back.  These  are  the  common  carotid 
and  the  vertebral  artery.  The  pulsation  of  the  artery  may  be 
felt  in  the  jugulum.  For  the  purpose  of  ligating  it  we  make 
an  oblique  incision  at  the  anterior  margin  of  the  right  sterno- 
mastoid  muscle,  extending  from  its  middle  third  to  the  anterior 
surface  of  the  manubrium  of  the  sternum.  Skin  and  fascia  are 
divided  and  the  attachment  of  the  sternal  portion  of  the  sterno- 
mastoid  muscle  is  separated  from  the  sternum.  Two  veins  are  to 
he  preserved :  the  transverse  connection  of  the  two  venae  me- 
dianae  colli  in  the  notch  of  the  sternum  and  the  transverse  vein 
behind  the  attachment  of  the  muscle.  Thus  we  reach  behind 
the  sterno-clavicular  articulation  the  common  carotid  artery. 
The  right  inferior  vena  thyreoidea  is  to  be  ligated  and  cut.  The 
lateral  margin  of  the  sterno-hyoid  and  sterno-thyroid  muscles  is 
incised  transversely  and  these  muscles  are  drawn  in  a  median 
direction  together  with  the  branches  of  the  descending  hypo- 
glossal nerve,  and  finally  the  deep  fascia  is  severed.  Between 
the  sterno-mastoid  and  the  other  muscles  we  follow  the  carotid 
down  to  its  junction  with  the  subclavian  under  which  the  trunk 
of  the  innominate  is  ligated ;  the  pleura  lying  postero- externally 
must  be  protected.  The  left  innominate  vein,  coming  from  the 
left,  lies  in  front  of  the  artery.  The  vagus  aiid  the  loop  of  the 
recurrent  laryngeal  remain  laterally  and  so  does  the  j)hrenic 
nerve. 

59.  Excision  of  the  Diseased  Thyroid  Gland. — The  descrip- 
tion here  given  for  this  operation  is  based  on  a  case  of  moderate 
severity.     For  slighter  cases,  i.e. ,  movable  circumscribed  nodules 


108  OPERATIVE   SURGERY. 

of  struma,  it  is  best  to  use  the  method  which  we  designate  as 
enucleating  resection.  Very  difficult  cases  can  be  undertaken 
only  by  a  surgeon  who  has  gathered  experience  in  less  com- 
plicated excisions. 

The  best  cicatrices  result  from  the  transverse  curved  incision 
(collar  incision,  Fig.  7)  along  the  cutaneous  folds,  but  this  gives 
less  ready  access  and  is  therefore  to  be  reserved  for  the  slighter 
cases.  Amply  sufficient  room  for  all  cases  is  furnished  by  the 
angular  incision.  This  begins  at  the  height  of  the  thyroid  car- 
tilage on  the  prominence  of  the  sterno-mastoid  muscle,  passes 
transversely  in  the  direction  of  the  cutaneous  fold  as  far  as  the 
median  line,  and  then  down  along  this  to  the  jugulum.  In 
more  deeply  seated  struma  it  is  prolonged  to  the  manubrium 
sterni.  In  the  transverse  portion  we  divide  the  skin  and 
platysma,  and  toward  the  median  line  the  thick  mediana  colli 
vein  which  is  doubly  ligated.  The  external  jugular  vein  is 
preserved.  After  the  superficial  fascia  is  sufficiently  divided  the 
muscles  are  laid  bare.  The  sterno-mastoid  is  drawn  outward. 
At  its  anterior  margin,  as  a  rule,  a  vein  must  be  ligated  (the 
connecting  branch  between  the  external  and  median  jugular 
veins) .  In  the  median  line  the  fascia  is  divided  which  unites 
the  sterno-laryngeal  muscles ;  above  the  sternal  notch  a  trans- 
verse vein  is  often  ligated.  The  medial  margin  of  the  last- 
named  muscles  is  freed  and  the  finger  is  inserted  beneath  them 
so  that  their  upper  end  may  be  incised  but  not  severed,  the 
vessels  belonging  to  the  upper  stump  being  ligated.  Then  these 
muscles  likewise  are  drawn  aside  with  hooks. 

The  connective-tissue  layer,  which  is  usually  thin,  is  then 
lifted  above  the  goitre,  whose  capsule  is  raised  and  divided  until 
the  brownish -red  or  bluish  surface  of  the  goitre  with  its  thick 
veins  is  exposed.  The  finger  is  passed  carefully  around  the 
goitre  so  as  to  make  sure  that  no  larger  veins  run  anteriorly  or 
laterally  from  the  capsule  to  the  surface  of  the  struma.  Should 
this  not  be  the  case,  the  struma  is  lifted  and  displaced  forward 


THE   ANTERIOR   CERVICAL   TRIANGLE.  109 

over  the  withdrawn  muscles.  This  is  especially  desirable  in 
cases  associated  with  marked  symptoms  of  pressure  and  stenosis, 
because  this  step  suddenly  relieves  the  trachea  and  respiration 
becomes  easy.  But  it  should  be  done  only  when  no  large  veins 
are  torn  thereby.  Accessory  veins  often  pass  from  without  to 
the  surface  of  the  goitre  and  must  be  doubly  ligated  before  the 
luxation. 

Where  the  goitre  can  be  turned  sufficiently,  we  see  and  feel 
behind  it  the  inferior  thyroid  artery  and  associated  vein ;  these 
pass  in  a  curve  from  without  toward  the  attachment  of  the 
tumor  to  the  trachea  and  can  be  ligated.  This  should  be  done, 
however,  only  after  careful  isolation,  because  the  vessels  are 
crossed  by  the  recurrent  nerve ;  for  the  same  reason  the  artery 
is  not  severed  but  merely  tied. 

We  now  turn  to  the  upper  or  lower  pole  of  the  tumor,  which- 
ever is  more  readily  isolated.  When  the  struma  is  not  deep, 
i.e.,  when  the  lower  cornu  does  not  extend  into  the  thorax,  we 
isolate  at  the  lower  pole  the  inferior  thyroid  vein,  which  is 
usually  very  thick  and  near  the  goitre  divides  into  several 
branches.  These  vessels  become  tense  when  the  tumor  is  lifted 
and  can  be  doubly  ligated  and  cut  without  fear  of  incidental 
injury. 

The  external  capsule  being  properly  separated  as  far  as  the 
upper  pole,  we  seize  the  superior  cornu  at  its  upper  end  and 
thus  isolate  the  upper  pedicle  with  the  superior  thyroid  artery 
and  vein,  which  are  included  in  a  common  double  ligature  (very 
firmly  tied)  and  divided. 

At  the  upper  and  lower  margin  of  the  thyroid  isthmus  we 
find  respectively  a  communicating  superior  and  inferior  vein, 
and  now  and  then  an  artery  of  the  pyramidal  process  above. 
If  possible  they  are  ligated  separately.  Then  a  struma  sound 
can  be  passed  between  the  trachea  and  isthmus  and  the  latter 
surrounded  with  a  strong  ligature  and  divided  under  traction. 

Usually  more  or  less  of  the  thyroid-gland  tissue   remains 


110  OPERATIVE   SURGERY. 

normal  and  may  be  preserved.  To  this  end,  after  the  goitre  has 
"been  freed  as  far  as  the  isthmus,  it  may  be  rested  on  the  fingers 
of  the  left  haod,  thus  lifted  out  and  stretched,  and  the  incision 
carried  through  the  tissue  parallel  to  the  trachea  at  some  dis- 
tance from  the  isthmus  as  far  as  the  nodule.  The  bleeding  ves- 
sels are  ligated  while  the  median  circumference  of  the  nodule  is 
enucleated  without  cutting,  until  the  healthy  glandular  sub- 
stance at  the  posterior  surface  is  reached,  when  this .  portion, 
too,  is  divided  at  some  distance  from  the  trachea.  By  this  enu- 
cleating resection  we  also  avoid  injuring  the  recurrent  nerve  at 
the  median  circumference  of  the  tumor.  A  semi-lateral  ex- 
cision should  never  be  made  until  we  have  assured  ourselves  of 
the  presence  of  a  lobe  on  the  other  side. 

J.  The  Lcwer  Lateral  Triangle  of  the  Neck, 

The  supra-clavicular  triangle  is  limited  by  the  clavicle,  the 
sterno-mastoid  muscle,  and  the  trapezius  muscle.  The  surgery 
of  this  region  is  simpler  than  that  of  the  upper  lateral  triangle  of 
the  neck.  Here  the  large  vessels  and  nerves  run  to  the  arm, 
and  here,  too,  we  strike  the  branches  of  the  subclavian  artery 
and  vein.  The  background  of  the  triangle  is  formed  by  the 
first  rib  and  the  first  intercostal  space,  together  with  the  lateral 
neck  muscles,  especially  the  scaleni.' 

The  normal  incision  (Fig.  25)  for  this  region,  which  corre- 
sponds to  the  cleavage  line  of  the  skin,  lies  almost  trans- 
versely, from  the  attachment  of  the  sterno-mastoid  muscle  at 
the  clavicle,  rising  somewhat  obliquely  to  the  margin  of  the 
trapezius.  The  incision  is  used  for  the  ligation  of  the  sub- 
clavian artery,  under  which  head  it  is  described. 

60.  Subclavian  Artery  (Figs.  24  and  25) . — This  vessel  springs 
from  behind  the  manubrium  sterni,  passes  over  the  pleura  of 
the  apex  of  the  lung,  over  the  first  rib  between  the  scalenus 
anticus  and  medius  muscles,  then  it  reaches  the  outer  surface 
of  the  thorax  under  the  middle  of  the  clavicle  between  the  sub- 


THE    LOWER    LATERAL   TRIANGLE    OF    THE    NECK.  Ill 

clavius  and  serratus  muscles.  It  can  be  with  certainty  com- 
pressed at  the  outer  margin  of  the  scalenus  anticus  muscle. 

In  order  to  ligate  the  vessel  a  transverse  incision  is  made, 
beginning  a  finger's  breadth  above  the  clavicle  on  the  clavicular 
portion  of  the  sterno  mastoid  muscle  and  extending  to  the  anterior 
margin  of  the  trapezius  muscle,  slightly  ascending  in  a  lateral 
direction.  After  dividing  the  skin  we  strike  the  platysma  and 
the  sensory  supra-clavicular  nerves  from  the  upper  cervical 
plexus,  which  suppl}^  the  upper  portion  of  the  thorax  and  the 
shoulder.  These  are  divided  transversely.  Then  the  fascia  is 
severed.  At  the  lateral  margin  of  the  sterno-cleido-mastoid 
muscle  the  external  jugular  vein  must  be  preserved ;  it  bends 
down  over  the  posterior  margin  of  the  muscle  toward  the  com- 
mon j  Ligular  vein  .  Lesion  of  this  vein  is  dangerous  because  the 
fascia  through  which  it  passes  keeps  it  tense  and  hence  air  may 
be  aspirated.  If  it  cannot  be  drawn  inward  it  must  be  doubly 
ligated  before  being  cut.  After  the  fascia  is  divided,  there  ap- 
pears in  the  inner  angle  of  the  wound  the  omo-hyoid  muscle, 
rising  obliquely  inward  in  the  adipose  tissue  of  the  triangle  with 
imbedded  glands.  In  this  adipose  tissue  lie  the  transverse  scap- 
ular artery  behind  the  clavicle,  the  superficial  cervical  artery 
ascending  posteriorly,  above  the  latter  but  under  the  deejD  fascia 
the  rathe]'  thick  transversa  colli  artery  which  passes  backward 
upon  or  through  the  nerve  plexus. 

After  removing  the  adij)ose  tissue,  the  thin  deep  fascia 
covers  the  brachial  plexus,  now  becoming  visible,  whose  thick 
nerve  trunks  emerge  between  the  scaleni  muscles  and  descend 
steeply  under  the  clavicle.  The  relation  of  the  artery  to  the 
nerve  plexus  is  very  characteristic.  If  we  pass  down  toward 
the  first  rib  along  the  anterior  surface  of  the  nerve  plexus  we 
find  the  attachment  of  the  scalenus  anticus  muscle  at  the  rib 
marked  by  a  prominence — the  tubercle  of  Lisfranc ;  behind  this 
the  artery  passes  covered  by  the  nerves.  In  a  median  direction 
from  the  scalenus  anticus  muscle  lies  the  bulb  of  the  common 


112 


OPERATIVE   SURGERY. 


jugular  vein ;  in  front  of  the  muscle  and  upon  the  first  rib,  the 
subclavian  vein,  hence  apart  from  the  artery.  On  the  anterior 
surface  of  the  scalenus  anticus  muscle  the  phrenic  nerve  passes 
into  the  thoracic  cavity.  Alongside  of  the  scalenus  muscle  the 
thoracic  duct  passes  from  the  thorax  into  the  neck  and  termi- 


Lateral 
pharyngotomy  ] 


Lingual  artery 
Hypoglossal  ner^e  r 
Superior  laryng  1  nerve  \ 

Common  carotid 


["Temporal  incision 
Thn-d  branch  of  trigeminus 
■j      nerve 

I  Middle  meningeal  artery 
L  Internal  maxillary  artery 


Accessory  nerve 
4.uricularis  magnus  nerve 
Internal  jugular  vein 
External  jugular  vein 

Mas^eter  muscle 
External  maxillary  artery 
External  maxillary  vein 

— Supraclavicular  nerves 
Trapezius  muscle 


Platysma 


j  Scalenus  medius 
I  muscle 


Sterno-mastoid  muscle 
External  jugular  vein 


Phrenic 


Transversa  colli  artery 
Brachial  plexus 
Transverse  scapular  artery 
I  Subclavian  artery 
Subclavian  vein 
Scalenus  anticus  muscle 


Fig.  40. 


nates  in  the  angle  between  the  subclavian  and  common  jugular 
veins. 

The  branches  of  the  subclavian  artery,  three  of  which  we 
have  already  mentioned,  spring  from  the  main  trunk  in  a  cen- 
tral direction  from  the  scaleni  muscles,  excepting  the  trans- 
versa colli.  The  guiding  points  for  finding  the  vertebral  and 
the  inferior  thyroid  artery  have  been  given  above. 


THE   LOWER   LATERAL   TRIANGLE    OF   THE   NECK.  113 

The  ligation  of  the  internal  mammary  artery  will  be  dis- 
cussed below. 

61.  The  external  branch  of  the  spinal  accessory  nerve  (Fig.  10) 
becomes  visible  in  the  lower  cervical  triangle  beneath  the  middle 
of  the  sterno-mastoid  muscle  immediately  under  the  first  fascia, 
that  is,  quite  superficially ;  its  course  is  obliquely  backward  to 
the  trapezius  muscle.  When  the  nerve  is  to  be  stretched  or 
divided  in  spasmodic  conditions  it  is  exposed  by  a  transverse 
incision  which  intersects  the  posterior  margin  of  the  sterno- 
mastoid  muscle  at  its  centre.     At  the  same  point  the 

62.  Subcutaneous  colli  nerve  and  the 

63.  Auricularis  magnus  nerve  surround  the  posterior  margin 
of  the  muscle. 

6tl:.  Through  the  normal  incision  for  the  lower  cervical  tri- 
angle may  be  exposed,  besides  the  large  nerve  trunks  of  the 
axillary  plexus,  also  all  its  shorter  branches.  They  spread  in  a 
conoidal  form  over  the  thorax,  posteriorly,  exteriorly,  and  an- 
teriorly. Posteriorly  we  have  the  dorsal  scapular  nerve  passing 
to  the  levator  scapulae  and  the  rhomboid  muscles,  through  the 
scalenus  medius ;  exteriorly,  the  suprascapular  nerve  passing  to 
the  incisura  scapulae  to  supply  the  supra-spinatus  and  infra- 
spinatus muscles;  the  axillary  nerve,  passing  along  the  lateral 
wall  of  the  axilla  between  the  teres  major  and  minor  on  the  one 
hand  and  the  anconseus  longus  and  humerus  on  the  other  hand 
to  the  lower  surface  of  the  deltoid  to  supply  the  latter,  the 
teres  minor,  and  by  a  sensory  branch  the  dorsal  side  of  the 
arm ;  the  subscapular  nerves  which  pass  at  the  posterior  wall 
of  the  axilla  to  the  teres  major,  subscapularis,  and  latissimus 
dorsi ;  the  thoracic  posticus  (longus)  nerve  which  extends  from 
the  medial  wall  of  the  axilla  to  the  serratus  anticus  major; 
anteriorly,  the  anterior  thoracic  nerves  which  surround  the  sub- 
clavian artery  and  pass  between  the  pectoralis  major  and  minor 
to  supply  these  two  muscles. 


114  OPERATIVE   SURGERY. 

K.  The  Nuchal  Region. 

The  surgery  of  the  upper  nuchal  region  has  been  discussed 
with  the  occiput  (which  see  for  the  occipital  artery  and  the 
major  and  minor  occipital  nerves). 

There  are  no  large  vessels  and  nerve  trunks  in  the  lower 
nuchal  region.  Incisions  are  very  often  made  at  the  nucha  in 
inflammations,  especially  furuncles  and  carbuncles.  Deep  in- 
cisions can  be  made  without  the  fear  of  wounding  important 
structures. 

For  opening  the  spinal  canal  see  the  dorsal  spine. 

L.  The  Thorax. 

The  main  indications  for  incisions  on  the  thorax  are  fur- 
nished by  diseases  of  the  pleura  and  the  ribs,  less  often  by  dis- 
ease of  the  lungs,  and  most  rarely  by  affections  of  the  pericar- 
dium. Among  the  larger  vessels  to  be  ligated  are  the  internal 
mammary  artery  and  the  intercostal  arteries,  but  above  all  the 
subclavian  artery  and  its  branches. 

65.  Internal  Mammary  Artery  (Fig.  36). — This  supplies  the 
inner  surface  of  the  anterior  thoracic  wall  and  its  branches  pass 
through  the  latter  to  the  skin.  With  its  concomitant  vein  it 
lies  upon  the  pleura  from  which  it  is  separated  by  a  very  thin 
layer  of  fascia  and  below  by  the  anterior  thoracic  muscle.  In 
front  the  artery  adjoins  the  costal  cartilages  and  the  intercostal 
muscles. 

It  is  ligated  through  a  transverse  incision  in  the  intercostal 
spaces  where  the  sternum  is  narrowest,  hence  by  preference  in 
the  second.  The  incision  is  carried  from  the  middle  of  the 
sternum  transversely  outward  between  the  costal  cartilages,  and 
divides  the  skin,  fascia,  and  the  pectoralis  major  muscle.  Now 
appear  the  obliquely  inward  descending  fibres  of  the  fascia  of 
the  external  intercostal  muscle  (ligamentum  corn  scans) ;   this 


THE   THORAX.  115 

fascia  is  often  very  thin  and  beneath  it  the  obliquely  outward 
descending  fibres  of  the  internal  intercostal  muscle  become  visi- 
ble. As  soon  as  these  are  divided  the  artery  is  seen  passing 
down  on  the  pleura,  about  0.5  to  1  cm.  from  the  edge  of  the 
sternum.     The  vein  lies  more  medial. 

GQ.  Intercostal  Artery  (Fig.  30). — The  main  branch  of  this 
artery  passes  between  the  two  intercostal  muscles  to  the  lower 
edge  of  the  rib,  while  a  smaller  branch  runs  along  the  upper 
edge.  Its  ligation  is  not  easy  because  the  artery  is  hidden 
under  the  overhanging  antero-inferior  edge  of  the  rib. 

The  external  intercostal  muscle  which  descends  obliquely  in- 
ward is  divided,  the  artery  is  surrounded  from  behind  with  a 
ligature,  very  carefully  lest  the  pleura  be  injured,  or  for  safety's 
sake  a  subperiosteal  resection  of  a  portion  of  the  covering  rib 
may  be  made. 

67.  The  intercostal  nerve  passes  below  the  artery  and  must 
be  drawn  aside.  It  can  be  exposed  like  the  artery  in  order  to 
be  stretched  in  neuralgias. 

68.  Thoracotomy . — The  best  method  for  the  free  opening 
of  the  pleural  cavity  is  that  preceded  by  resection  of  the  ribs. 
For  mere  puncture  we  enter  between  the  ribs,  nearer  to  their 
upper  than  their  lower  edge,  on  account  of  the  nerves  and  the 
larger  vessels.  The  skin  is  pressed  as  deeply  as  possible  into 
the  intercostal  space,  and  the  trocar  vigorously  pushed  in  beside 
the  finger  above  the  upper  edge  of  the  rib.  For  large  trocars  a 
small  cutaneous  incision  is  made  first. 

69.  For  resection  of  the  ribs  (Fig.  36)  the  incision  is  made 
over  their  largest  curvature,  parallel  to  both  margins.  In  cut- 
ting directly  upon  the  bone  no  larger  vessel  or  nerve  is  injured, 
only  the  covering  skin  and  muscle.  After  the  periosteum  is 
divided  it  is  very  carefully  detached  with  an  elevator,  above, 
below,  and  behind  the  rib,  and  a  piece  cut  out  of  the  latter, 
thus  laid  bare,  with  strong  bone  forceps. 

Behind  the  rib,  covered  besides  the  periosteum  with  a  very 


116 


OPERATIVE    SURGERY. 


^^'  y 


thin  fascia  (the  endothoracic) ,  Hes  the  pleura,  which  can  then  at 
once  be  incised  in  the  direction  of  the  exsected  rib,  the  presence 
of  the  exudation  having  been  determined,  in  doubtful  cases,  by 
puncture. 

Very  often  the  resection  of  a  single  rib  does  not  suffice.  In 
such  a  case  the  upper  rib  is  cut  in  like  manner  (Fig.  41)  through 

the  same  cutaneous  incision,  the 
skin  being  drawn  strongl}^  up- 
ward; a  piece  is  resected  also 
from  this  rib  and  the  underlying 
pleura  opened  likewise  longitu- 
dinally as  with  the  first  rib.  An 
aneurism  needle  is  now  passed 
at  the  lateral  and  medial  end  of 
the  two  pleural  incisions  under 
the  intervening  tissues  of  the 
intercostal  space,  the  vessels  are 
ligated  together  with  the  pleura 
and  muscles,  and  after  this  is 
done  the  two  pleural  incisions 
are  connected  in  the  centre  by 
a  vertical  cut ;  thus  we  obtain  a  gaping  opening  in  the  form 
of  a  recumbent  H  (I) . 

If  permanent  drainage  is  to  be  provided  for,  the  opening 
must  be  made  in  the  lowest  part  of  the  cavity.  In  the  line  of  the 
nipple  we  still  strike  the  pleural  cavity  after  removal  of  the  car- 
tilage of  the  sixth  rib.  In  the  lateral  region  the  pleura  is  struck 
on  the  right  after  removal  of  the  ninth  rib  and  on  the  left  even 
of  the  tenth  rib ;  behind  in  both  scapular  lines  after  removal  of 
the  twelfth  rib.  But  there  is  a  contra-indication  to  the  incon- 
siderate opening  of  the  pleura  at  these  lowest  limits,  especially 
with  pointed  instruments,  because  the  diaphragm  of  the  anterior 
chest  wall  might  immediately  adjoin  it;  it  is  advisable,  there- 
fore, to  open  the  pleural  cavity  at  first  at  the  point  where  fluid 


Fig.  41.— Free  Opening  of  the  Thorax,  with 
Resection  of  two  Ribs. 


THE   THORAX.  117 

is  sure  to  be  met,  i.e.,  where  its  presence  has  been  determined 
by  aspiration.  Only  after  free  access  has  been  gained  here  a 
sound  is  introduced  to  the  lowest  part  of  the  cavity,  or  else  this 
is  ascertained  by  the  finger  from  within.  A  second  opening  is 
then  made  in  the  same  way  by  costal  resection  at  the  latter 
point  and  through-drainage  thus  provided  for. 

70.  Resection  of  Larger  Portions  of  the  Chest  Wall. — Ex- 
tensive excisions  of  the  chest  wall  are  apt  to  be  called  for  in 
pleural  disease  with  retraction  of  the  lung,  where  a  closure  of 
the  pus  cavity  is  mechanically  impossible  through  rigidity  of 
the  wall :  in  neoplasms,  especially  chondromata  and  sarcomata 
of  the  ribs  which  have  involved  the  pleura.  The  operation 
bears  Estlander's  name,  although  isolated  extensive  resections 
were  performed  and  reported  before  his  time  (De  Cerenville). 

Through  every  large  incision  running  parallel  to  the  ribs  a 
number  of  ribs  can  easily  be  resected.  But  if  larger  portions  of 
the  chest  wall  must  be  removed  in  one  piece,  flap  incisions  are 
required.  For  these  two  directions  are  to  be  recommended :  in- 
cision beginning  at  the  anterior  axillary  fold,  running  obliquely 
backward  and  downward  over  the  lateral  surface  of  the  thorax 
between  the  attachments  of  the  serratus  anticus  major  and  the 
latissimus  dorsi  posteriorly  and  the  external  oblique  of  the  abdo- 
men anteriorly.  To  this  is  added  an  oblique  incision  along 
one  of  the  ribs  at  the  desired  height.  The  second  direction  of 
the  incision  runs  vertically  along  the  margin  of  the  extensors  of 
the  back  to  the  posterior  angles  of  the  ribs,  dividing  the  tendi- 
nous portion  of  the  latissimus  and  partly  of  the  trapezius  and 
serratus  posticus  inferior.  To  this  incision,  which  runs  from 
above  downward  and  strikes  the  border  line  of  the  large  mus- 
cular regions  and  their  nerve  twigs,  is  likewise  added  a  second 
incision  parallel  to  the  course  of  the  ribs,  according  to  re- 
quirements. 

Yl.  Operations  on  the  Lungs. — At  any  desired  point  where 
abscesses,  cavities,  or,  exceptionally,  new-formations  in  the  puU 


118  OPERATIVE    SURGERY. 

monary  tissue  call  for  interference,  the  lung  may  be  exposed  in 
the  same  manner  as  the  pleural  cavity  is  opened ;  with  this  dif- 
ference, however,  that  we  must  be  sure,  either  by  adhesions 
artificially  induced  (cauterization)  or  by  direct  fixation  previous 
to  free  opening,  that  the  portion  of  the  lung  in  question  is 
kept  in  contact  with  the  chest  wall,  unless  adhesions  have  been 
caused  by  the  disease. 

For  the  opening  of  cavities  at  their  most  frequent  seat, 
namely,  the  apex,  the  operation  is  performed  as  follows : 

Incision  through  skin,  fascia,  and  pectoralis  major  muscle 
along  the  first  intercostal  space,  parallel  to  the  clavicle,  and  in 
a  lateral  direction  from  its  sternal  end.  Division  of  both  inter- 
costal muscles,  medially  only  the  internal.  At  this  point  the 
internal  mammary  artery  should  not  be  injured,  nor  the  sub- 
clavian vein  at  the  lateral  end-  of  the  incision. 

At  the  lower  edge  of  the  first  rib  the  periosteum  on  its 
anterior  surface  is  divided  and  carefully  displaced  forward  and 
backward ;  then  the  lower  two-thirds  of  the  rib  are  resected, 
leaving  a  bridge  above,  lest  any  of  the  large  vessels  resting 
upon  the  rib  be  injured.  Aspiration  with  a  hypodermic  syringe 
is  now  resorted  to  in  order  to  determinp  the  position  of  the 
cavity,  a  small  incision  is  made  through  the  pleura,  and  en- 
larged with  a  pair  of  arterial  forceps. 

M.  Opening  of  the  Spinal  Canal. 

Horsley  by  his  brilliant  operations  has  shown  the  excellent 
results  to  be  obtained  by  relieving  the  pressure  on  the  cord 
caused  by  tumors,  even  in  very  advanced  cases,  and  other  sur- 
geons have  reached  equally  satisfactory  effects  by  relieving  the 
pressure  due  to  fracture  and  luxations  of  the  vertebrae  or  by 
opening  abscesses. 

72.   The  operation  is  performed  in  the  following  manner: 
Long  median  incision  down  to  the  spinous  processes,  detach- 


LUMBAR   REGION.  ]  10 

ment  of  the  muscles  on  both  sides  with  the  knife,  close  to  the 
bone  (especially  the  transverso-spinalis  muscle),  if  necessary  by 
the  aid  of  transverse  nicking  of  the  thick  covering  fascia.  The 
exposed  spinal  processes  are  removed  at  their  base  with  bone 
forceps,  together  with  the  interspinal  ligaments.  The  posterior 
arches  are  removed  by  making  a  transverse  incision  through  the 
stout  intercrural  (flava)  ligaments  along  the  upper  and  lower 
margin  of  the  arches  close  to  the  bone.  The  arches  are  severed 
on  both  sides  and  lifted  out,  one  after  the  other,  until  the  cord 
is  sufficiently  exposed. 

Adipose  tissue  and  large  vessels  (circuli  venosi)  are  divided 
with  the  knife  and  ligated  if  necessary,  then  the  dura  is  opened 
in  the  median  line.  Of  course,  v/hen  the  pressure  is  due  merely 
to  a  displaced  or  broken  vertebra,  or  an  extradural  tumor  or 
abscess,  the  dura  is  not  opened. 

Even  when  the  dura  has  been  opened,  a  complete  suture  is  to 
be  applied  after  drainage,  and  thus  healing  by  first  intention 
may  be  secured  in  the  course  of  forty-eight  hours. 

N.  Lumbar  Region. 

73.  Nephrotomy  and  Nephrectomy  (Fig.  42). — The  incisions 
for  exposing  the  kidney  best  illustrate  the  normal  incision  for 
the  lumbar  region.  Nephrotomy  is  performed  for  wandering 
kidney  so  as  to  fasten  the  organ  to  the  skin  and  fascia,  for 
opening  the  pelvis  and  the  calyces  of  the  kidney  in  hydrone- 
phrosis, pyonephrosis,  nephrolithiasis,  and  neoplasms.  Neph- 
rectomy is  performed  for  the  total  removal  of  the  kidney  in 
the  case  of  tumors  and  extensive  disease  by  lithiasis,  inflamma- 
tions, and  tuberculosis.     The  same  incision  exposes  the  ureter. 

The  correct  direction  is  a  transverse  incision  beginning  on 
the  prominence  of  the  sacro -lumbar  muscle  and  passing  under 
the  twelfth  rib  to  the  anterior  axillary  line.  It  divides  the  skin, 
subcutaneous  tissue,  the  thick  lumbo-dorsal  fascia  with  its  cor- 


120  OPEKATIVE    SURGERY. 

responding  muscles,  the  latissimus  dorsi  and  beneath  it  the  ser- 
ratus  posticus  inferior.  The  most  lateral  serration  of  the  former 
muscle  appears  as  a  flat,  thick  muscular  bundle.  The  remaining 
part  of  the  muscle  is  cut  laterally  from  the  sacro-lumbar  mar- 
gin, as  are  the  thin  fibres  of  the  serratus  posticus  inferior  which 
ascend  obliquely  outward  and  are  not  always  recognized  as  a 
separate  layer.  The  sacro-lumbalis  is  slightly  nicked  at  its 
margin  or  vigorously  drawn  in  a  median  direction  with  a  blunt 
hook.  In  the  case  of  longer  incisions  the  external  oblique  ab- 
dominal muscle  with  its  descending  fibres  is  transversely  divided 
for  a  short  distance,  and  at  its  posterior  margin  and  beneath  it 
the  obliquely  ascending  fibres  of  the  internal  oblique  are  treated 
in  the  same  way.  At  the  margin  of  the  sacro-lumbalis  and 
between  the  divided  ends  of  the  above-mentioned  two  abdominal 
muscles  appears  the  tense,  glistening  lumbo-costal  fascia,  from 
which  spring  the  fibres  of  the  transversus  abdominis  muscle. 

After  this  fascia  is  divided,  the  margin  of  the  quadratus 
lumborum  muscle  becomes  visible,  running  almost  vertically 
and  parallel  to  the  margin  of  the  sacro-lumbalis;  beneath  it 
appears  the  twelfth  intercostal  nerve  with  its  concomitant  thick 
vessels,  passing  antero-inferiorly.  The  first  lumbar  (ilio-hypo- 
gastric)  nerve  descends  more  deeply  than  the  twelfth  intercostal, 
at  the  margin  of  the  quadratus  muscle.  Anteriorly  the  nerves 
perforate  the  transversus  and  pass  between  it  and  the  obliquus 
internus  muscle.  They  are  drawn  upward  and  downward,  and 
the  vessels,  if  necessary,  are  ligated  and  cut. 

At  the  lateral  margin  of  the  quadratus  muscle,  which  ac- 
cording to  requirements  may  be  nicked  or  withdrawn,  under  the 
thin  transverse  fascia  lies  the  abundant  retro-renal  loose  adipose 
tissue,  with  vessels.  A  finger  is  inserted,  carefully  separates 
these  tissues  (capsula  adiposa),  and  reaches  the  kidney  without 
meeting  with  resistance.  For  nephroraphy  the  thin  fibrous 
capsula  propria  which  covers  the  kidney  tensely  is  nicked  and 
detached  from  the  organ  without  cutting. 


LUMBAR  REGION. 


121 


Lumbo-dorsal  fascia 
Sacro-lumbalis  rausscle 
Serratus  posticus  mfe 

rior  muscle 
Latissimus  dorsi  muscle 
Lumbo-costal  fascia 


Glutasus  maxim  us  m. 

Glutseus  medius  m. 

Super' r  gluteal  artery 

Pyriformis  muscle 

Tip  of  the  great  I 
trochanter      f 


Base  of  the  great ) 
trochanter       ( 


Latissimus  dorsi  muscle 
Tw  elf th  mtercostal  nerve 
Quadratus  lumboiiim  m. 
First  lumbar  nerve 
Transverse  abdominal  m. 
Ext  1  abdoni'l  oblique  m. 
Int  1  abdom'l  oblique  m. 
Posterior  super"  r  spine 
of  the  ilium 

3  Postenoi  infer'r  spine 
(  of  the  ilium 


J  Glutseus  maximus 
1  muscle 

Int'l  pudendal  artery 
Int'l  pudendal  nerve 
Pyriformis  muscle 
Sciatic  artery 
Sciatic  nerve 
Posterior  cutaneus 
femoris  nerve 
j  Obturator  internus 
m.  (withgemeUi) 


Fig.  4-Z. — Nephrotom.y.    Gluteal  and  sciatic  arteries. 


122  OPERATIVE   SURGERY. 

If  the  kidney  is  to  be  luxated  in  toto  for  examination,  inci- 
sion, or  excision,  the  detachment  of  the  fibrous  capsula  propria  is. 
omitted.  The  renal  pelvis  can  be  palpated  from  behind  by  passing^ 
the  finger  toward  the  hilus,  the  ureter  lying  behind  the  vessels. 

The  renal  pelvis  is  incised  directly  from  behind  if  it  is  dilated  j 
in  other  cases  it  is  better  to  make  a  short  longitudinal  incision 
from  the  convexity  of  the  kidney  and  insinuate  the  finger  in  the 
direction  of  the  hilus  as  far  as  the  pelvis  of  the  kidney. 

Where  the  parenchyma  of  the  kidney  has  been  injured  it  is  ad- 
visable to  adopt  the  open  wound  treatment  or  secondary  suture, 
not  only  on  account  of  the  discharge  of  the  urine,  but  because, 
according  to  our  experience,  gained  by  the  aid  of  Dr.  Tavel,  in- 
juries to  the  kidney  are  apt  to  infect  the  neighborhood.  The 
kidney  usually  contains  (by  excretion?)  micro-organisms  which 
give  rise  to  inflammation.  For  this  reason  it  is  a  good  plan  to 
prepare  such  patients  for  the  operation  by  the  administration  of 
salol,  45  grains  pro  die. 

As  regards  nephrectomy  we  have  in  recent  years  invariably 
adhered  to  the  practice  of  lengthening  the  transverse  incision  so 
far  forward  as  to  strike  the  transition  fold  of  the  peritoneum 
adjoining  the  colon,  which  comes  within  the  region  of  the  axil- 
lary line,  and  to  open  the  peritoneum  first  at  this  point.  From 
here  we  always  succeed  in  insinuating  the  hand  far  enough  into 
the  abdominal  cavity  to  palpate  the  other  kidney,  ascertain  its 
size  and  consistence,  and  feel  the  renal  artery.  After  deter- 
mining the  presence  of  a  well-developed  kidney  on  the  opposite 
side,  the  peritoneum  was  sutured  and  the  operation  performed 
in  the  above-described  manner. 

Y4.    Ureter. — The  ureter  can  be  exposed  at  various  points: 

a.  At  its  lowest  point ;  see  Exposure  of  the  seminal  vesicles 
and  vasa  deferentia  from  the  perineum,  in  surgery  of  the  peri- 
neal region,  and  from  the  posterior  pelvic  incision. 

h.  On  the  internal  iliac  fossa ;  see  Ligation  of  the  common 
iliac  artery. 


ABDOMEN,  123 

c.  In  the  neighborhood  of  the  kidney  by  the  same  incision  as 
for  nephrotomy ;  or,  in  case  it  must  be  followed  for  some  dis- 
tance downward,  by  a  longitudinal  incision  along  the  margin  of 
the  sacro -lumbar  muscle. 

75.  In  an  analogous  manner  to  the  kidney  the  spleen  can  be 
exposed  on  the  left  side,  the  incision  being  lengthened  forward. 
We  abstain  from  giving  a  detailed  description  because  the 
method  of  operation  depends  too  largely  on  the  individual  rela- 
tions of  the  case,  especially  the  size  and  nature  of  the  tumors. 

O.  Abdomen. 

Normal  Incisions. — Access  to  the  contents  of  the  abdomen 
is  obtained  with  the  least  amount  of  incidental  injury  by  a  ver- 
tical incision  in  the  anterior  median  line.  No  large  vessels  are 
met  with,  aside  perhaps  from  an  unobliterated  umbilical  vein 
and  a  few  veins  in  the  subserous  adipose  tissue. 

The  incision  divides  the  skin,  superficial  fascia,  and  the  linea 
alba,  i.e.,  the  union  of  the  aponeuroses  of  the  recti  abdominis 
muscles.  Beneath  this  lies  the  transverse  fascia  and  under  this 
the  peritoneum,  covered  with  more  or  less  subserous  fat.  Above 
and  below  the  peritoneum  can  be  displaced  on  the  linea  alba ;  in 
the  region  of  the  umbilicus  it  adheres  firmly. 

For  the  deeper  organs  lying  more  laterally  the  median  inci- 
sion does  not  always  suffice,  i.e..,  it  inflicts  an  unnecessary  in- 
jury because  the  intestines  present ;  especially  organs  near  the 
hypogastrium  and  hypochondrium  are  too  far  for  a  median  in- 
cision. The  rather  common  lateral  longitudinal  incisions  along 
the  margin  of  the  rectus  abdominis  muscle  should  be  rejected 
because  they  divide  the  nerves  supplying  the  latter  muscle.  In 
the  case  of  long  incisions  this  drawback  should  not  be  under- 
valued, especially  in  the  upper  part  of  the  abdomen.  Paralysis 
of  the  muscle  favors  the  development  of  abdominal  hernias. 

Aside  from  the  median  incision  the  onlv  rational  ones  with 


124  OPERATIVE   SURGERY, 

reference  to  the  course  of  the  nerves  are  transverse  incisions 
(Fig.  36)  or  transverse  oblique  incisions  placed  parallel  to  the 
nerve  trunks.  It  is  true  these  transverse  incisions  divide  the 
three  broad  abdominal  muscles,  but  the  nerves  lying  between 
the  several  layers,  especially  the  internal  oblique  and  the  trans- 
versus,  can  be  pushed  out  of  the  way.  Even  the  rectus  abdo- 
minis is  less  injured  by  a  transverse  incision  than  by  a  longi- 
tudinal one  made  laterally,  because  the  motor  nerves  remain 
intact  and  merely  an  artificial  inscriptio  tendinea  is  superadded 
so  that  the  muscle  contracts  as  before.  Still  in  transverse 
incisions  the  superior  and  inferior  epigastric  artery  must  be  cut 
and  ligated. 

Hypochondrium. 

Y6.  Cholecystotomy  (Fig.  36), — The  following  is  the  proce- 
dure for  opening  and  eventually  removing  the  gall  bladder. 
Oblique  transverse  incision  4  to  6  cm,  below  the  free  border  of 
the  ribs,  10  to  15  cm.  in  length.  It  begins  three  fingers'  breadth 
from  the  median  line  on  the  prominence  of  the  rectus  abdominis, 
divides  the  skin,  superficial  fascia,  and  the  fascia  of  the  internal 
oblique ;  in  front  of  the  rectus  the  two  fascias  are  united.  Un- 
derneath appears  the  rectus,  whose  lateral  half  is  divided ;  the 
superior  epigastric  artery  under  its  lateral  margin  being  ligated. 
In  the  lateral  portion  the  external  abdominal  oblique  muscle  is 
cut,  and  still  farther  away  the  internal  oblique  and  the  trans- 
versus.  Beneath  these  the  terminal  branches  of  the  intercostal 
nerves  pass  obliquely  inward  toward  the  rectus.  Smaller  per- 
forating twigs  of  these  nerves  are  met  with  in  the  first  fascia. 

Beneath  the  muscles  appears  the  transverse  fascia,  quite 
thick  at  this  point,  with  its  transverse  fibres,  and  after  it  is 
divided  the  peritoneum  is  reached.  When  the  latter  is  opened 
the  gall  bladder  can  be  seen  and  removed  if  it  is  lengthened  and 
enlarged. 

For  cholecystectomy  the  visceral  peritoneum  must  be  divided 


ABDOMEN.  125 

parallel  to  the  border  of  the  liver,  at  the  apex  of  the  fundus  of 
the  bladder,  and  the  gall  bladder  detached  subperitoneally,  with- 
out cutting,  as  far  as  the  cystic  duct ;  the  artery  vesicae  felleae 
being  ligated.  The  duct  is  doubly  ligated  and  divided.  Since 
micro-organisms  may  migrate  from  the  intestine  into  the  bile 
ducts,  the  peritoneum  must  be  protected  with  sterilized  pledgets, 
and  after  the  duct  is  cut  the  stumps  must  be  disinfected  by  means 
of  sublimated  cotton  or  the  thermo -cautery. 

Hypogastrium . 

As  a  type  of  the  operations  in  the  region  of  the  lateral  hypo- 
gastria  we  may  instance  the  ligation  of  the  common  and  the 
external  iliac  artery.  In  the  case  of  the  former  we  enter  the 
peritoneum  by  an  incision  two  fingers'  breadth  above  Poupart's 
liagment.  In  the  case  of  the  latter  the  peritoneum  is  avoided 
by  keeping  close  to  Poupart's  ligament  and  dividing  only  the 
transverse  fascia  which  is  attached  to  it ;  while  the  peritoneum 
forms  a  reduplication  on  the  internal  iliac  fascia,  about  0.5  cm. 
above  (for  both  these  ligations  see  below) . 

In  an  analogous  manner  abscesses  of  the  internal  iliac  fossa 
can  be  opened  extra-peritoneally  by  proceeding  upon  or  beneath 
the  internal  iliac  fascia ;  or  else  we  may  proceed  after  opening 
the  peritoneum  if  the  vermiform  appendix  is  to  be  resected, 
tumors  of  the  caecum  are  to  be  removed,  or  if  on  the  left  side 
the  sigmoid  flexure  is  to  be  drawn  out  for  the  formation  of  an 
artificial  anus  or  for  removal  in  the  case  of  neoplasm.  A  trans- 
verse incision  from  one  side  to  the  other,  from  the  right  anterior 
inguinal  ring  to  the  one  on  the  opposite  side,  is  indicated  when 
the  bladder  is  to  be  opened  (compare  Fig.  T). 

The  inguinal  canal  is  opened  directly  in  its  course  when  the 
spermatic  cord  is  to  be  exposed  in  castration,  or  the  round  liga- 
ment is  to  be  sought,  or  finally  if  the  neck  of  a  hernial  sac  situ- 
ated in  the  canal  is  to  be  reached  (herniotomy). 


126  OPERATIVE   SURGERY. 

Exposure  of  the  Inguinal  Canal  (for  herniotomy,  castra- 
tion, varicocele  operation,  and  Alexander's  prolapsus  operation). 

YT.  Castration.  Excision  of  the  Tunica  Vaginalis  (Fig.  Y) . 
— Transverse  incision  along  the  inguinal  canal  one  finger's 
breadth  above  Poupart's  ligament,  running  in  a  median  direc- 
tion downward  parallel  to  the  median  third  of  the  ligament. 
The  incision  corresponds  exactly  to  the  cleavage  line  of  the  skin 
and  therefore  adheres  very  readily.  In  the  subcutaneous  tissue 
and  superficial  fascia  a  thick  vein  descending  from  above  is  to  be 
ligated  without  and  within.  The  superficial  epigastric  artery, 
ascending  from  the  femoral  artery  across  the  abdominal  wall, 
is  severed  with  the  external  vein  if  the  incision  is  lengthened 
laterally.  Then  follows  division  of  the  thin  external  fascia  of 
Cooper,  which  incloses  the  spermatic  cord,  and  is  a  delicate  con- 
tinuation of  the  fascia  of  the  external  abdominal  oblique  muscle ; 
of  the  muscular  fibres  of  the  cremaster  (from  the  internal 
oblique)  laterally  from  the  last-named  fascia ;  and  of  the  thick 
infundibuliform  fascia  (a  continuation  of  the  transverse  fascia). 
This  contains  the  spermatic  cord,  or,  respectively,  the  round 
ligament  and  possibly  diverticula  of  the  peritoneum  in  the  shape 
of  hernial  sacs.  In  the  case  of  castration  it  is  easy  to  turn  the 
testicle  upward,  unless  it  is  adherent  to  the  scrotum  or  greatly 
enlarged,  and  remove  it,  or  to  replace  it  if  no  more  is  intended 
than  the  division  and  excision  of  the  tunica  vaginalis  in  hydro- 
cele vaginalis  and  funiculi. 

When  the  testicle  is  adherent  or  the  seat  of  larger  tumors 
the  castration  is  performed  by  means  of  a  transverse  incision  in 
a  frontal  direction  at  the  lower  end  of  the  scrotum.  After  the 
skin  and  dartos  tunic  (Fig.  7)  are  divided  between  the  visible 
larger  scrotal  vessels,  the  testicle  with  its  envelopes  is  turned 
out.  As  the  incision  is  parallel  to  the  scrotal  vessels  (external 
scrotal  arteries) ,  so  it  is  also  on  the  surface  of  the  vaginal  tunics 
parallel  to  the  branches  of  the  vessels  of  the  spermatic  cord 
passing  to  the  lower  pole. 


ABDOMEN.  127 

Y8.  Inguinal  Herniotoiny. — The  incision  for  this  operation  is 
-exactly  like  that  for  the  exposure  of  the  spermatic  cord  descriljed 
above.  After  sufficient  division  of  the  cremaster  and  especially 
of  the  infundibuliform  fascia,  the  neck  of  the  hernial  sac  can 
generally  be  readily  isolated,  without  cutting,  from  the  struc- 
tures belonging  to  the  spermatic  cord  and  lifted  by  traction  from 
the  scrotum  as  far  as  its  rounded  lower  end.  The  limits  of  a 
thin  hernial  sac  can  also  be  rendered  apparent  by  stretching  the 
tissues  of  the  spermatic  cord  and  holding  them  to  the  light. 

For  the  radical  operation  uj^vvard  the  hernial  sac  is  carefully 
isolated  and  vigorously  drawn  down,  until  the  portion  lying  in 
the  posterior  inguinal  ring  can  be  seized,  stitched  with  silk 
thread,  and  strongly  ligated  in  two  directions.  After  being 
cut  off  below,  the  ligated  portion  is  entirely  withdrawn  into  the 
abdomen.  Then  a  series  of  deep  sutures  are  placed  through  the 
fascia  of  the  external  oblique  and  the  muscular  fibres  under- 
neath so  as  to  narrow  the  entire  length  of  the  inguinal  canal. 

79.  Isolation  of  the  Round  Ligament  (Fig.  43). — The  round 
ligament  in  the  female  sex  is  isolated  in  an  analogous  manner 
to  the  spermatic  cord.  But  the  operation  is  much  easier  because 
of  the  absence  of  the  cremaster  and  of  a  distinct  infundibuliform 
fascia.  The  placing  of  the  incision  depends  upon  the  way  the 
ligament  is  to  be  stitched,  in  retroversion,  retroflexion,  and  pro- 
lapsus uteri.  We  have  obtained  very  good  results  from  the 
following  modification  of  Alexander's  operation : 

The  entire  length  of  the  incision  is  carried  the  breadth  of  the 
little  finger  above  Poupart's  ligament  through  the  skin,  the 
superficial  fascia,  and  above  the  inner  half,  ?'.e.,  above  the  in- 
guinal canal,  through  the  fascia  of  the  external  abdominal 
oblique.  The  superficial  hypogastric  artery  in  the  superficial 
fascia  together  with  the  vein,  and  a  vein  ascending  vertically  at 
the  inner  angle  of  the  wound,  are  ligated.  The  round  ligament 
with  the  accompanying  thin  vessel  can  now  at  once  be  isolated 
out  of  the  groove  of  Poupart's  ligament  without  resort  to  the 


128 


OPERATIVE   SURGERY. 


knife.  The  round  ligament  is  freed  from  its  peripheral  attach- 
ments toward  the  symphysis  and  vigorously  drawn  out  in  the 
direction  toward  the  anterior  superior  iliac  spine.  We  can 
readily  convince  ourselves  on  the  cadaver  that  by  this  means 
the  uterus  is  drawn  up,  bent  forward,  and,  if  the  operation  is 


Round  ligament  turned  outward 

Cone  of  peritoneum  withdrawn 
Point  to  which  the  continuous  / 
suture  extends  ) 

Fascia  of  the  external  oblique,  divided- 
Anterior  inguinal  ring,  divided 


Fig.  43. 


done  bilaterally,  held  so  tensely  on  both  sides  as  to  remain  fixed 
in  its  new  position. 

But  the  round  ligament  carries  with  it  a  cone  of  parietal 
peritoneum  about  3  cm.  long.  As,  soon  as  we  have  convinced 
ourselves  that  no  intestines  have  come  forward  with  this  cone, 
the  ligament  is  stitched  with  a  continuous  silk  suture  to  the 
fascia  of  the  external  oblique.  The  suture  includes  also  the  per- 
itoneal cone,  begins  at  the  anterior  superior  iliac  spine,  and 
extends  to  the  posterior  inguinal  ring.  Then  the  inguinal  canal 
is  again  closed  with  deep  sutures  (compare  No.  Y8). 

80.  Resection  of  the  Vermiform  Appendix. — The  method  of 
operation  can  here  be  only  outlined  for  cases  in  which  the  ap- 
pendix is  resected  in  the  intervals  between  relapsing  inflamma- 
tions, and  in  the  absence  of  perityphlitic  or  paratyphlitic  exu- 
dations and  abscess. 


ABDOMEN.  120 

The  incision  (see  Fig.  7)  is  like  that  for  the  ligation  of  the 
common  iliac  artery  but  shorter,  two  fingers'  breadth  above  the 
right  anterior  superior  iliac  spine,  along  the  external  half  of 
Poupart's  ligament  and  extending  beyond  its  middle.  The  dif- 
ferent layers  are  divided  as  in  the  ligation  of  the  above-named 
artery,  but  the  peritoneum  is  likewise  opened  in  the  line  of  the 
incision.  If  possible  the  caecum  is  drawn  out,  otherwise  the 
appendix,  whose  situation  varies,  is  sought,  freed  from  adhe- 
sions, and  withdrawn.  Its  mesentery  is  cut  between  two  liga- 
tures. One  centimetre  from  the  attachment  of  the  appendix  to 
the  csecum  the  serous  and  muscular  coats  are  cut  around  and 
dissected  off ;  finally  the  mucosa  is  surrounded  with  silk  thread 
as  close  as  jjossible  to  the  csecum  and  severed,  and  the  stump  is 
touched  wi^h  the  thermo -cautery  so  as  to  disinfect  it.  Then  it 
is  turned  in  and  stitched  over  it  with  a  continuous  silk  suture. 

81.  Formation  of  a  Fecal  Fistula  (Fig.  44). — In  every  case 
in  which  the  intestinal  gases  cannot  be  expelled  and  thus  give 
rise  to  respiratory  and  nutritive  disturbances,  the  temporary 
formation  of  a  fecal  fistula  may  be  indicated,  especially  in  ileus 
in  the  more  restricted  sense  and  in  peritonitis.  By  gaining  time 
many  a  life  can  be  saved.  The  operation,  when  correctly  per- 
formed, is  absolutely  free  from  danger  and  therefore  should  not 
be  postponed  too  long. 

The  abdominal  wall  is  incised  at  various  points,  preferably, 
where  choice  is  possible,  two  to  three  fingers'  breadth  above  the 
middle  of  Poupart's  ligament,  and  parallel  to  it,  for  a  distance 
of  6  cm.  After  dividing  the  abdominal  wall  down  to  the  peri- 
toneum, the  latter  is  nicked  to  a  less  extent,  say  2  to  2.5  cm. 
As  a  rule  a  tense  loop  of  intestine  at  once  presents  in  the  wound 
and  is  so  arranged  as  to  fill  the  whole  width  of  the  wound  witL- 
out  being  drawn  out  in  any  way.  Then  a  button  suture  is  in- 
serted in  each  of  the  four  directions,  to  include  the  intestinal 
and  the  parietal  serosa  with  the  fascia,  but  away  from  the  peri- 
toneal wound   (Fig.  44),  so  as  to  fasten  the  intestine  to  the 


130  OPERATIVE   SURGERY. 

abdomiaal  wall.  After  this  follows,  corresponding  to  the  edge 
of  the  peritoneal  opening,  an  uninterrupted  fine  silk  suture 
which  kermetically  presses  the  parietal  and  the  intestinal  serosa 
together.  In  the  centre  of  the  opening  thus  made  a  quick  short 
insdsion  is  made  with  a  small  knife  and  a  sound  is  introduced  to 

Parietal  peritoneum 

Fascia  of  the  external  abdominal  oblique 
Transverse  fascia 

Surface  of  intestine 


Fig.  44.— Formation  of  a  Fecal  Fistula. 

make  sure  that  the  lumen  of  the  intestine  has  been  reached. 
The  wound  is  powdered  with  iodoform  oraristol,  and  warm  0.1^ 
salicylated  water  compresses  are  applied  and  frequently  changed. 
82.  Formation  of  an  Artificial  Anus  (Fig.  45). — A  small 
fecal  fistula  always  suffices  for  the  temporary  evacuation  of  the 
intestine  in  tympanites.  An  artificial  anus,  therefore,  is  formed 
only  in  cases  where  a  permanent-discharge  and  protection  of  the 
inferior  intestine  from  the  contents  are  intended.  The  opera- 
tion is  performed  in  the  following  manner :  Incision  two  fingers' 
breadth  above  Poupart's  ligament,  extending  laterally  from  its 
middle.  After  opening  the  abdominal  wall  as  for  fecal  fistula 
by  dividing  the  three  muscular  layers  and  fascia,  and  the  peri- 
toneum to  a  less  extent,  the  intestine — for  instance,  the  sigmoid 
flexure  in  impassable  rectal  cancer — is  drawn  into  the  wound 
until  a  complete  loop  is  present.  This  is  stitched  to  the  parietal 
peritoneum  with  a  continuous  silk  suture  so  that  the  afferent 
portion  of  the  intestine  has  ample  room,  while  the  efferent  por- 
tion is  compressed  by  the  former.     Then  a  triangular  piece  is 


ABDOMEN. 


131 


resected  from  the  convexity  of  the  loop  as  far  as  the  attach- 
ment of  the  mesentery.  Unless  opening  is  urgent  it  should  be 
jjostponed  until  good  adhesions  have  formed  (two  days) . 

83.  Resection  and  Suture  of  the  Intestine  (Figs.  46  and  47), 
— If  gangrenous  hernise,  constrictions,  or  new -formations  call 

Skin 
Abdominal  wall 

Parietal  peritoneum 


Fig.  45.— Formation  of  an  Artificial  Anus. ' 


for  the  removal  of  a  portion  of  the  intestine,  the  first  care 
should  be,  not  only  that  the  resection  be  made  in  healthy  tissue, 
but  also  at  the  points  where  a  free  mesenteric  blood  supply  is 
assured.  The  intestine  is  not  divided  quite  transversely,  but  in 
a  somewhat  oblique  line,  so  that  a  little  more  is  removed  from 
the  convexity  so  as  to  make  sure  of  the  circulation  on  that  side 
of  the  intestinal  wall  which  is  farthest  from  the  mesentery. 
The  latter  is  never  unnecessarily  extirpated,  even  where  it  lies  in 
thick  folds,  but  always  divided  as  close  to  the  gut  as  possible, 
along  its  attachment. 

For  the  suture  the  extremities  of  the  gut  must  be  placed  in 
a  handy  position  outside  the  abdominal  cavity  if  at  all  possible, 
then  the  mesenteric  portions  of  the  two  intestinal  lumina  are  first 
brought  in  contact  by  a  silk  button  suture,  whose  ends  are  left 
long.  Next  a  second  button  suture  is  placed  at  the  convexity 
through  both  intestinal  lumina.     The  intestinal  wall  being:  now 


'  The  figure  represents  the  operation  on  the  right  instead  of  the  left  side  and 
therefore  should  be  reversed  for  the  flexure. 


132 


OPERATIVE    SURGERY. 


turned  in  toward  the  lumen  until  broad  surfaces  of  the  serous 
covering  are  in  contact  (Lembert),  a  continuous  and  reliable 
silk  suture  is  placed,  which  must  include  the  muscular  and^' 
serous  tissues  and  be  drawn  very  tight.  Over  this  first  suture 
is  placed  a  second  (after  Czerny  and  Kocher)  uninterrupted  fine 

silk  suture  through  the 


serosa  only,  the  first  end 
of  the  thread  being  tied 
to  the  last.  A  thorough 
cleansing  with  0.  ^%  table - 
salt  solution  at  98.6°  F.  is 
followed  by  another  with 
0.1%  sublimate  solution, 
and  every  trace  of  this 
fluid  is  again  removed 
with  warm  salt  water. 


If 


Fig.  46. 


Fig.  47. — Intestinal  Resection  and  Circular  Intestinal 
Suture.    Longitudinal  section. 


84.  High  Supra-Pubic  Cystotomy  (Fig.  Y). — The  bladder  in- 
cision above  the  symphysis  is  at  present  the  normal  procedure 
for  opening  the  bladder  for  very  different  indications,  as,  con- 
trary to  the  perineal  operation,  it  enables  us  to  secure  healing 
by  first  intention.  The  normal  incision  runs  transversely  in  the 
fold  above  the  symphysis  through  the  fat,  skin,  and  fascia  so  as 
to  expose  the  recti.  In  the  Trendelenburg  position  with  its 
high  elevation  of  the  pelvis  this  permits  a  very  good  view  upon 


ABDOMEN,  133 

and  into  the  bladder.  Some  vertical  veins  are  to  be  severed  and 
ligated.  In  order  to  gain  sufficient  room  without  exposing  the 
peritoneum  to  danger,  the  soft  parts  above  the  symphysis  are 
freely  divided,  and  the  incision  is  carried  in  a  curve  from  the 
region  above  one  inguinal  canal  to  the  same  point  on  the  oppo- 
site side.  The  attachments  of  the  recti  muscles  to  the  symphysis 
are  partly  severed  with  the  pyramidal  muscles.  In  the  depth  a 
longitudinal  division  of  the  median  line  through  the  linea  alba 
(united  fascia  of  the  abdominal  recti)  is  added.  The  finger  is 
introduced  behind  the  symphysis  and  draws  up  the  thin  fascia, 
the  subserous  fat,  and  with  it  the  reduj)lication  of  the  perito- 
neum which  can  be  seen  or  felt  as  a  transverse  fold  or  promi- 
nence. 

This  manipulation  in  conjunction  with'  the  high  position  of 
the  pelvis  renders  unnecessary  the  elevation  of  the  bladder  by 
filling  it  or  the  rectum.  The  latter  measures  are  not  without 
danger  from  rupture  or  injury  of  these  organs  when  diseased. 
It  is  desirable  to  draw  a  firm  loop  of  thread  through  the  entire 
thickness  of  the  muscular  layer  at  the  lowest  point  of  the 
bladder  which  can  be  readily  reached.  In  the  same  way  a 
second  loop  is  passed  through  the  muscular  tissue  of  the  vertex 
of  the  bladder  at  the  peritoneal  fold.  The  introduction  of  such 
loops  materially  facilitates  the  subsequent  suture  after  the  blad- 
der has  been  evacuated. 

Between  the  two  loops  the  muscular  tissue  is  divided  in  a 
vertical  direction  until  the  mucosa  projects  as  a  bluish  vesicle. 
Hemorrhages  are  at  once  arrested.  On  puncturing  this  protru- 
sion the  urine  (or  the  aseptic  solution  introduced  into  the  bladder) 
spurts  out  and  the  incision  can  be  extended  according  to  re- 
quirements for  the  extraction  of  a  stone,  excision  of  a  neojDlasm, 
or  mere  inspection  and  digital  exploration  of  the  bladder.  The 
mucosa  does  not  need  as  large  an  opening  as  the  muscular  coat, 
being  very  elastic.  The  bladder  is  closed  with  a  two-tiered 
suture,  the  first  extending  to  the  mucosa,  the  superficial  one 


134  OPERATIVE   SURGERY. 

(uninterrupted)  including  the  covering  cellular  tissue  with  the 
muscular  coat.     Then  follows  the  closure  of  the  external  wound. 

Before  the  operation  the  bladder  has  been  thoroughly  irri- 
gated and  filled  with  150  to  200  ccm.  of  boiled  4:%  boric  acid 
solution  at  98.6°  F. 

For  the  after-treatment  a  Nelaton  catheter  is  introduced 
through  the  urethra  to  which  it  is  fastened  by  a  silk  thread  car- 
ried through  the  frenulum,  and  the  urine  is  permanently  con- 
ducted through  a  rubber  tube  into  a  bottle  filled  with  5^  car- 
bolic acid  (or  0.1^  sublimate)  solution,  placed  close  to  the 
bed.  The  catheter  remains  in  place  from  one  to  two  weeks 
until  the  healing  of  the  bladder  wound  is  assured,  A  drainage 
tube  is  inserted  as  far  as  the  bladder  through  the  skin,  as  tisual 
through  a  separate  small  opening,  and  exceptionally  allowed  to 
remain  for  eight  to  ten  days. 

85.  Opening  of  the  Bladder  ivith  Resection  of  the  Symphysis. 
— Where  a  large  transverse  incision  does  not  afford  sufficient 
room  for  operations  in  and  upon  the  bladder,  it  is  best  to  follow 
Helferich's  procedure:  after  separating  the  attachments  of  the 
nauscles  (above,  the  abdominal  recti  and  pyramidales;  below 
externally,  the  obturatores  extern!)  a  triangular  wedge  with 
broad  upper  base  and  the  point  above  the  pubic  arch  is  resected 
subperiosteally  from  the  symphysis  and  the  periosteum  on  the 
posterior  surface  properly  detached.  This  manipulation  does  no 
further  injury  to  the  firmness  of  the  pelvis.  Dr.  Niehans  makes 
the  symphyseal  resection  on  one  side  only,  but  does  it  thor- 
oughly. 

P.  Perineum. 

The  perineal  region  appears  rather  complicated  anatomically, 
especially  as  regards  the  fasciae. 

Operations  on  the  perineum  are  intended  to  expose  the 
lowest  part  of  the  rectum,  the  urethra,  the  prostate  and  seminal 
vesicles,  the  vagina,  the  uterus,  and  the  base  of  the  bladder. 


PERINEUM.  1 35 

The  operation  which  formerly  occupied  the  foreground  and  fur- 
nished the  most  frequent  indication  was  lithotomy. 

86.  Perineal  lithotomy  was  looked  upon  as  the  normal  pro- 
cedure until  quite  recently,  the  only  question  having  been  the 
selection  of  the  most  appropriate  method  among  its  different 
varieties — lateral  incision,  bilateral  incision,  median  incision. 
That  the  incision  from  below  has  been  practised  so  long  is  to  be 
explained  by  the  fact  that  the  infection  of  the  wound  in  the 
high  operation  could  not  be  prevented,  while  in  the  perineal 
operation  at  least  the  escape  of  the  urine  and  the  wound  secre- 
tions could  be  provided  for,  so  that  their  infiltration  into  the 
tissues  would  not  increase  the  danger  of  infection. 

At  present  the  only  definite  indication  for  perineal  lithotomy 
is  in  those  rare  cases  in  which  small  stones  cannot  be  removed 
by  lithotripsy,  though  they  are  too  large  to  pass  through  the 
intact  urethra. 

In  such  cases  the  urethral  incision  is  made  in  the  membra- 
nous portion  and  the  perineal  incision  coincides  with  external 
urethrotomy.  The  latter  is  performed,  moreover,  in  lacerations, 
strictures,  fistulse,  for  digital  exploration  of  the  bladder,  and 
finally  for  the  removal  of  foreign  bodies  from  the  bladder  and 
urethra.  Other  indications  for  the  perineal  incision  are  ab- 
scesses and  neoplasms  of  the  prostate  and  seminal  vesicles. 

Excepting  the  middle  lobe  which  often  projects  into  the 
bladder,  the  prostate  is  best  made  accessible  from  the  perineum, 
and  Dittel  and  Zuckerkandl  have  given  minute  directions  for 
the  operation.  Diseases  of  the  uterus  are  treated  through  the 
vagina,  diseases  of  the  rectum  preferably  through  a  posterior 
incision  (see  Surgery  of  the  posterior  pelvic  region).  Still,  the 
prostate  with  the  seminal  vesicles  can  also  be  very  well  reached 
through  this  posterior  incision  beside  and  beyond  the  rectum. 

87.  Opening  of  the  Cavernous  and  Bulbous  Portion  of  the 
Urethra.  Median  Incision. — A  median  incision  is  made  down 
to  the  fibrous  albuginea  of  the  corpus  cavernosum.     Unless  the 


136 


OPERATIVE    SURGERY. 


latter  requires  opening  or  removal  for  disease,  the  urethra  is 
reached  beside  the  lateral  circumference  of  the  corpus  caver - 
nosum,  especially  beside  the  bulb,  one  of  the  wound  margins 
being  drawn  aside. 

88.   Opening  of  the  Membranous  and  Prostatic  Portion  of 
the  Urethra.     Normal  Incision  for  Giving  Free  Access  (Figs. 


Fig.  48. 


48  and  49). — This  operation  also  gives  access  to  the  prostate, 
seminal  vesicles,  and  the  urethral  extremity  of  the  vasa  defe- 
rentia.  It  requires  a  large  external  opening,  hence  the  median 
incision  is  at  once  out  of  the  question.  A  purely  lateral  inci- 
sion, such  as  was  formerly  made  by  preference,  divides  the  ves- 
sels and  nerve  twigs  passing  from  the  internal  pudendal  artery 
and  nerve  toward  the  median  line  (posteriorly  the  external 
hemorrhoidal  arteries  and  nerves,  anteriorly  the  perineal  and 
bulbosa  artery,  with  the  nerves  running  parallel  to  them).     Al- 


PERINEUM. 


137 


tliough  sacral  resections  have  shown  that  the  unilateral  division 
of  these  nerves  does  not  necessarily  lead  to  permanent  motor 
disturbances,  still  injury  of  these  structures  is  to  be  avoided  on 
principle,  and  the  transverse  curved  incision  is  to  be  considered 
the  normal  procedure  for  giving  free  access. 

The  incision  begins  on  the  right  between  the  tuber  ischii  and 


Fig.  49. 


rectum,  passes  forward  to  the  posterior  end  of  the  palpable  bul- 
bus  urethr^e,  and  symmetrically  backward  on  the  opposite  side. 
After  dividing  the  skin  and  the  sujDerficial  thin  fascia,  we 
reach  the  ischio-rectal  excavation  laterally  in  the  adipose  tissue 
between  the  pelvis  and  rectum.  This  is  separated  without  cut- 
ting as  far  as  the  lower  surface  of  the  levator  ani  muscle. 
During  this  step  the  external  hemorrhoidal  nerve  and  artery  are 
pushed   or   draw^n   backward,    the   perineal   nerve   and    artery 


138  OPERATIVE    SURGERY. 

(trans versus  perinei)  and  the  bulbosa  forward.  Close  to  the 
bulb  the  connecting  fibres  between  the  external  sphincter  ani 
and  the  bulbo-cavernosus  muscle  are  divided  transversely  and 
the  bulbus  urethrse  is  drawn  forward.  The  superficial  trans- 
versus  perinei  muscle  remains  in  front.  At  the  anterior  sur- 
face of  the  rectum  an  organic  muscle-fibre  layer  connects  the 
bundles  of  the  levator  ani  muscle  transversely.  This  is  covered 
by  a  fascia  in  front  which  rises  to  Douglas'  pouch.  At  the 
point  where  this  fascia  joins  the  deep  layer  of  the  pelvic  fascia 
over  the  bulb  it  is  severed  and  drawn  backward,  together 
with  the  above-named  muscular  layer  and  the  lower  end  of  the 
rectum.  In  this  way  the  posterior  circumference  of  the  uro- 
genital diaphragm  is  exposed,  namely,  below  the  triangular 
urethral  ligament,  above  the  posterior  broad  margin  of  the  deep 
transversus  perinei  muscle  which  covers  the  membranous  por- 
tion of  the  urethra  as  far  as  the  prostate. 

Within  the  deep  transversus  perinei  muscle  Cowper's  glands 
are  situated,  and  may  there  be  rendered  accessible. 

Working  upward  along  the  diaphragm  without  cutting,  the 
fibres  of  the  levator  ani  muscle,  which  run  in  the  sagittal  plane 
postero-inferiorly,  are  displaced  to  both  sides,  and  thus  we  reach 
the  smooth  posterior  surface  of  the  prostate  and  higher  up  the 
seminal  vesicles  which  can  be  made  clearly  visible.  The  latter 
are  loosely  united  with  the  peritoneum  and  may  be  easilj"  de- 
tached up  to  their  upper  end.  Should  the  incision  fail  to  give 
sufficient  room,  it  can  be  lengthened  backward  on  both  sides, 
the  sacro-tuberous  ligament  being  severed  at  its  attachment  to 
the  tuber  ischii. 

89.  Internal  Pudendal  Artery  at  the  Perineum,  and  Internal 
Pudendal  Nerve  at  the  Perineum. — Incision  close  to  the  easily 
palpable  tuber  ischii,  passing  along  the  medial  border  of  the 
pubic  arch  forward  through  the  skin.  The  fascia  is  divided, 
sparing  the  cutaneous  branch  of  the  pudendal  nerve  which 
passes  to  the  scrotum.     In  the  anterior  portion  the  belly  of  the 


SACRAL   REGION.  139 

ischio-cavernosus  muscle  is  exposed.  Close  to  its  attachment 
the  superficial  transversus  periuei  muscle  is  severed  at  the  as- 
cending ramus  of  the  ischium,  and  at  the  same  time  the  deep 
layer  of  the  fascia  is  divided  vs^hich  forms  the  inferior  covering 
of  the  uro-genital  diaphragm,  and  is  reflected  on  the  inner  sur- 
face of  the  internal  obturator  muscle.  The  artery  lies  on  the 
inner  surface  of  the  last-named  muscle,  passing  forward  above 
the  attachment  of  the  sacro-tuberous  ligament;  the  internal 
pudendal  nerve  lies  beside  it  and  more  superficially. 

Q,.  Sacral  Region. 

Since  the  conviction  has  gained  ground  that,  in  those  cases 
in  which  intra-peritoneal  exposure  of  the  pelvic  organs  is  im- 
possible or  contra-indicated,  access  from  behind  is  for  various 
reasons  preferable  to  that  from  the  perineum,  the  surgery  of  the 
sacro-coccygeal  region  has  acquired  a  greater  interest. 

90.  The  rectum  in  particular  is  often  exposed  from  behind 
for  the  extirpation  of  neoplasms,  but  this  way  is  also  employed 
for  reaching  the  upper  part  of  the  vagina,  the  uterus,  the  pros- 
tate, the  base  of  the  bladder,  and  the  seminal  vesicles. 

The  cutaneous  incision  (normal  incision)  begins  at  the  side 
of  the  gluteal  fold,  usually  the  left,  in  the  groove  between 
the  depressed  sacrum  and  the  prominence  of  the  glutseus  max- 
imus,  two  fingers'  breadth  below  the  superior  posterior  iliac 
spine.  It  passes  downward  to  the  median  line  and  along  this 
to  the  tip  of  the  coccyx  at  the  posterior  margin  of  the  anus, 
eventually  circling  around  the  latter  into  the  raphe  of  the  per- 
ineum. 

Along  the  sacrum  the  attachment  of  the  glut?eus  maximus 
is  severed  and  the  edge  of  the  bone  laid  bare.  At  the  margin 
of  the  sacrum  the  ligaments  and  muscles  are  divided  and  we 
enter  the  depth  by  the  side  of  the  bone  (Zuckerkandl,  Wolfler). 
A  better  view  is  gained  by  the  extirpation  of  the  coccyx,  accord- 


140 


OPERATIVE   SUKGERY. 


ing  to  the  method  used  by  Verneuil  for  imperforate  anus  and 
employed  by  Kocher  for  the  excision  of  the  rectum.  Where 
necessary  a  portion  of  the  sacrum  is  likewise  resected,  either 


Ketro-rectal  fascia  with  fat 
Levator  ani  muscle  V  \ 
External  sphiocter  ^ 


Fat 


Incision  of  glutseus  maximus  muscle 


Anus 

Divided  coccyge°us*^muscle  |  '    Pjnfoimit,  muscle 

Divided  sacro-tuberous  and  sacro-spinous  ligaments  oacrum  ( attacnment  oi  gluteus 

^  "  maximus  muscle) 


Left  seminal  vesicle 
Vas  deferens 


Divided  sacro-tuberous  and 
sacro-spinous  ligaments 


External  sp'iincter     /      Base  of 
Levator  ani  muscle      bladder 

Rectum  drawn  out  toward  the  right       Sacruni    Pyrif  ormis  muscle 
Fig.  50. — Parasacral  Posterior  Pelvic  Incision. 


the  left  margin  only  or  a  large  piece  as  far  as  the  fourth,  third, 
or  even  the  second  sacral  foramen  according  to  Kraske's  method. 
We  may  go,  at  least  on  one  side,  as  far  as  the  second  sacral 


SACRAL   REGION.  141 

foramen  without  causing  permanent  injury,  although  the  nerves 
for  the  bladder  and  rectum  are  derived  from  the  fourth  and 
fifth  sacral  nerves  and  the  internal  pudendal  from  the  third 
sacral. 

If  the  bone  is  not  resected,  we  sever  at  the  left  margin  of 
the  sacrum  and  on  both  sides  of  the  coccyx  the  attachment  of 
the  tuberoso-sacral  and  spinoso-sacral  ligaments;  of  the  attach- 
ments of  the  muscles,  from  above  downward,  the  pyriformis, 
the  coccygeal,  and  ischio-coccygeal ;  below  the  tip  of  the  coccyx 
the  levator  ani  and  sphincter  ani.  If  the  coccyx  is  removed,  it  is 
exarticulated  with  the  resection  knife ;  if  a  portion  of  the  sacrum 
is  resected,  it  is  divided  with  a  few  powerful  blows  of  the  chisel 
and  its  lower  end  dissected  out  in  its  entire  width  in  connection 
with  the  coccyx.  This  occasions  often  rather  free  hemorrhage, 
both  from  the  divided  bone  and  especially  from  the  sacral 
arteries  (sacralis  media  and  lateralis),  the  former  derived  from 
the  aorta,  the  latter  from  the  hypogastric.  As  these  vessels 
closely  adjoin  the  sacrum  they  are  at  times  hard  to  seize  and  to 
ligate,  and  a  temporary  tamponade  must  be  resorted  to.  At 
the  lowest  part  of  the  rectum  the  thick  prominence  (several 
centimetres  high)  of  the  external  and  internal  sphincter  ani 
with  the  median  levator  is  to  be  divided  if  the  anal  portion  is 
to  be  enucleated.  Alongside  of  the  rectum  the  levator  ani 
muscle  is  divided  to  the  raphe  of  the  perineum ;  during  this  step 
some  branches  of  the  external  hemorrhoidal  artery  (from  the 
internal  pudendal)  will  spirt. 

For  exposing  the  rectum  higher  up  the  main  conditions  are, 
first,  the  proper  detachment  of  the  connections  with  the  anterior 
surface  of  the  sacrum,  of  the  sacro- coccygeal  muscle  and  liga- 
ments ;  second,  the  thorough  division  of  the  peritoneum  in  the 
region  of  Douglas'  pouch,  which  in  the  male  reaches  down  to 
the  palpable  upper  margin  of  the  prostate,  in  the  female  to  the 
fornix  vaginae.  After  the  peritoneum  is  divided  the  rectum 
can  be  so  far  withdrawn  that  a  portion  20  to  25  cm.  distant 


142 


OPEEATIVE   SURGERY. 


from  the  anus  may  be  stitched  into  the  anal  ring  without  using 
force.  In  freeing  the  rectum  higher  up,  branches  of  the  median 
hemorrhoidal  artery  (from  the  hypogastric)  and  of  the  internal 
hemorrhoidal  artery  (from  the  inferior  mesenteric)  must  be  li- 
gated ;  the  thickest  branches  lie  laterally.  After  the  fascia  is 
severed  and  the  vessels  coming  from  the  side  and  behind  are 


Anterior  circumflexa  humeri  artery 
Musculo-cutaneous  nerve 
Musculo-cutaneous  nerve 
Brachial  artery  | 


Brachial  artery 
Deep  brachial  artery  and  radial  nerve 


Fig.  51. 


ligated,  the  rectum  can  be  withdrawn  from  the  wound  with  a 
large  blunt  hook,  so  that  after  dividing  the  frontal  prerectal 
layer  of  the  fascia  the  upper  circumference  of  the  prostate  and 
the  seminal  vesicles  with  the  inferior  end  of  the  vas  deferens 
can  be  distinctly  seen  along  with  the  base  of  the  bladder.  Near 
the  upper  end  of  the  seminal  vesicles  in  an  outward  direction 
the  inferior  extremity  of  the  ureter  can  also  be  exposed. 


UPPER   EXTREMITY. 


143 


R.  Upper  Extremity. 

a.   Sliouhler  Jieyion. 

91.  Subclavian  Artery  by  Transverse  Incision  (Figs.  51  and 
52). — Incision  1  cm.  below  the  middle  third  of  the  clavicle, 
dividing  the  iSbres  of  the  platysma  with  the  sensory  supra- 


Long  head  of  biceps 
Circumflexa  anterior  humeri  artery 
Cephalic  vein 
Deltoid  muscle 
Pectoris  major  m.  , 
Brachialis  internus  m 
.M I  ;sci  I  In-cutaneous  n 

BiCH-V's  ,  \ 


Biceps  muscle 
Median  nerve 
Brachial  artery 
I  Laeertus  fibrosus  bicipitis 
Brachial  artery 
Median  vein 
Brachio-radialis  muscle 


Pectoralis  major  muse 
Subclavian 
Subclavian  muscle 
Subclavian  arter 
Cephalic  vein 
Deltoid  muscle 
Root  of  me- 
dian and 
ulnar  nerves 


M  '/  /     ^.•■. 


Anterior  thoracic 
nerves 


Fig.  53. 


clavicular  nerves.  The  cephaHc  vein  at  the  anterior  margin  of 
the  deltoid  is  to  be  preserved  when  the  fascia  is  divided.  The 
clavicular  portion  of  the  pectoralis  major  is  severed  to  the  mar- 
gin of  the  deltoid.  Beneath  the  clavicle  the  tense  fascia  of  the 
subclavian  muscle  is  divided  and  drawn  down  together  with  the 
cephalic  vein  which  passes  to  the  subclavian.  The  axillary 
plexus  lies  deeper  and  outward.  Between  the  most  medial 
nerve  trunk  (ulnar  with  cutaneus  medius)  and  the  vein  lies 
the  artery  on  the  serratus  anticus  muscle. 


144 


OPERATIVE   SURGERY. 


92.  Under  the  subclavian  muscle  the  superior  thoracic 
artery  (Figs.  51  and  52)  branches  from  the  main  trunk  and  at 
the  same  point  the  latter  is  surrounded  by  the  motor  branches 
to  the  pectoralis  major  and  minor,  namely,  the  anterior  thoracic 
nerves. 

Subclavian  Artery  by  Longitudinal  Incision  (Fig.  36). — 
Incision  upon  the  clavicle,  beginning  at  the  limit  between  the 
middle  and  outer  third,  extending  in  the  palpable  furrow  be- 


Axillary  artery 


Subscapular  artery 


Thoracica  longa  artery 


Fig.  53. 


tween  the  deltoid  muscle  and  the  clavicular  portion  of  the  pec- 
toralis major  muscle  toward  the  axillary  fold.  After  the  skin 
is  divided  the  cephalic  vein  appears  in  the  fascia  and  is  drawn 
to  the  medial  side  if  the  artery  is  to  be  ligated  close  under  the 
clavicle.  But  this  has  the  drawback  that  a  point  is  exposed 
where  the  important  anterior  thoracic  nerves  pass  from  without 
and  above  over  the  artery  in  their  course  to  the  pectoral  muscles. 


UPPER   EXTREMITY. 


Uo 


Where  the  choice  is  free,  therefore,  the  cephahc  vein  is 
drawn  laterally  upward.  Under  its  terminal  portion,  i.e.,  be- 
fore it  empties  into  the  subclavian  vein,  lies  the  artery  and 
laterally  from  it  the  nerve  trunks  of  the  axillary  plexus. 

98.  Under  the  upper  margin  of  the  pectoralis  minor  muscle 
below  which  the  artery  passes  we  strike  the  point  where  the 
thoracico-acromial  artery  is  given  off  (Fig.  36),  whose  branches 
lie  in  front  of  the  main  artery. 


'Tncep<5  mu'scl 
Ulnai  nerve 


Coraco-brachialis  niuseie 
Median  nerve 
Axillary  vein 


Teres  major  muscle 
Latissimus  dorsi  muscle 


Anconaeus  long-us  muscle 
Subscapular  artery 
Subscapular  nerve 
C'ircuniflexa  scapulae  aii«ry 
Thoracico-dorsalis  artery 

(  Subscapular  muscle  with 

■)  teres  minor 


Fig.  54. 


Detachment  of  the  pectoralis  major  for  a  short  distance 
along  the  clavicle  facilitates  the  operation. 

94:.  Long  Thoracic  Artery  (Fig.  58). — Incision  along  the 
anterior  axillary  fold,  the  arm  being  abducted,  beginning  at 
the  lateral  surface  of  the  thorax.  After  the  fascia  is  divided 
the  artery  is  found  directly  behind  the  margin  of  the  pec- 
toralis major,    passing   down   the   thorax  or  the    serratus  an- 

10 


146  OPERATIVE   SURGERY. 

ticus  major  in  the  axillary  line.     Behind  it  lies  the  long  thoracic 
nerve. 

b.  Axilla. 

95.  Axillary  Artery  (Figs.  53  and  54). — Direction  from  the 
middle  of  the  clavicle  to  the  middle  of  the  anterior  axillary  fold. 
It  lies  on  the  lateral  wall  of  the  triangular  prismatic  space  be- 
tween the  thoracic  wall  interiorly  (serratus  anticus  major)  ^ 
pectoralis  major  and  minor  anteriorly,  and  scapula,  (subscapular 
muscle)  posteriorly.  Incision  through  skin  and  fascia  in  the 
prolongation  of  the  internal  bicipital  sulcus,  extending  upward 
at  the  inner  margin  of  the  muscular  prominence  of  the  coraco- 
brachialis  which  appears  under  the  pectoralis  major  toward  the 
arm.  The  belly  of  the  coraco-brachialis  is  exposed.  The  axil- 
lary plexus,  which  is  palpable  even  through  the  skin  on  the 
rounded  eminence  of  the  head  of  the  humerus,  is  in  sight.  We 
pass  between  the  two  most  lateral  nerve  trunks.  The  thinner 
external  one  of  these  is  the  musculo- cutaneous,  the  thick  medial 
one  is  the  median;  sometimes  only  the  latter  is  visible.  Higher 
up  the  median  consists  of  two  parts,  the  lateral  one  of  which 
unites  with  the  musculo -cutaneous  nerve.  The  artery  lies  in  the 
fork  between  the  two  roots  of  the  median.  The  ulnar  nerve  lies. 
in  a  median  direction  from  the  vessel ;  the  radial  nerve  posteri- 
orly ;  the  chief  vein  quite  anteriorly ;  a  smaller  collateral  vein 
exteriorly  from  the  artery. 

96.  Anterior  Circumflex  Artery  (Figs.  51  and  52). — Incision 
at  the  anterior  margin  of  the  deltoid  at  the  point  where  the 
finger  can  be  pressed  in  upon  the  surgical  neck  of  the  humerus. 
On  the  fascia  lies  the  cephalic  vein.  It  is  important  for 
determining  the  furrow  between  the  deltoid  and  pectoralis. 
major.  After  dividing  the  fascia  the  muscles  are  separated 
from  each  other  without  cutting,  the  former  being  drawn  out- 
ward, the  latter  inward.  The  short  head  of  the  biceps  with  the 
coraco-brachialis,   which,  coming  from  above,  passes  under  tha 


UPPER  EXTREMITY.  147 

pectoralis,  is  freed  on  its  lateral  side  and  drawn  in  a  median 
direction.  We  enter  between  it  and  the  long  biceps  tendon. 
The  artery  runs  transversely,  adjoining  the  bone  close  under 
the  rounded  head,  above  the  attachment  of  the  pectoralis. 

97.  Posterior  Circumflex  Artery  and  Axillary  Nerve  (Figs. 
55  and  56). — Palpation  at  the  posterior  margin  of  the  deltoid 
muscle  toward  the  surgical  neck  of  the  humerus  will  distinctly 
feel  the  angle,  open  below,  formed  by  that  muscle  with  the 
posterior  scapular  muscles  or  the  teres  minor. 

After  dividing  the  skin  and  the  fascia  which  adheres  rather 
firmly  to  the  deltoid,  the  margin  of  the  latter  is  freed  and  drawn 
upward,  then  upward  and  backward  the  lower  margin  of  the 
teres  minor  is  exposed  above  the  teres  major  and  latissimus 
muscles  lying  in  the  posterior  axillary  fold.  In  the  angle 
formed  by  the  margins  of  the  teres  minor  and  deltoid  the  tissues 
are  separated  without  cutting  toward  the  bone,  the  long  head 
of  the  anconaeus  which  projects  under  the  teres  minor  being 
left  in  the  rear.  First  appears  the  thick  axillary  nerve  which 
gives  off  a  cutaneous  branch  downward  along  the  margin  of 
the  deltoid.  Below  we  strike  the  posterior  circumflex  artery 
which  passes  from  the  space  between  the  teres  major  and  minor, 
and  whose  branches  pass  up  and  down. 

98.  Subscapular  Artery  and  Nerves  (Figs.  53  and  54). — In- 
cision on  the  arm,  beginning  along  and  above  the  posterior 
axillary  fold,  the  arm  being  strongly  abducted.  On  the  fascia, 
intercostal  roots  of  the  internal  cutaneous  nerve  may  appear. 
After  the  fascia  is  divided,  the  artery  becomes  visible  at  the 
upper  margin  of  the  latissimus  dorsi  muscle  (which  forms  the 
posterior  axillary  fold  with  the  teres  minor),  in  the  loose  adi- 
pose tissue.     The  trunk  is  short. 

09.  The  continuation  of  the  trunk  toward  the  thorax  is  the 
thoracico-dorsalis  artery,  accompanied  by  the  thick  subscapular 
nerves  which  come  from  above. 

100.   The   other   main   branch   is   the   circumflexa   scapula? 


148 


OPERATIVE   SURGERY. 


UPPER   EXTREMITY. 


149 


150  OPERATIVE   SURGERY. 

artery  which  passes  backward  between  the  latissimus  (with 
teres  major)  and  subscapular  muscles  on  the  medial  side  of  the 
anconseus  longus  muscle. 

c.  Arm. 

The  brachial  artery  may  be  felt  in  the  internal  bicipital 
sulcus  through  the  entire  length  of  the  arm,  below  the  equally 
palpable  median  nerve  which  crosses  the  artery  in  the  middle 
from  without  inward,  passing  over  it.  The  artery  can  be  com- 
pressed in  its  entire  length  against  th^  biceps. 

101.  Brachial  Artery  at  its  Middle  (Figs.  51  and  52). — In- 
cision upon  the  cord  of  the  median  nerve  which  can  be  distinctly 
felt  in  the  internal  bicipital  sulcus  when  the  arm  is  abducted. 
On  the  fascia  is  the  thin  internal  cutaneous  nerve.  The  fascia 
is  divided  to  expose  the  belly  of  the  biceps  muscle  which  is 
drawn  laterally.  The  median  nerve  is  completely  exposed  and 
separately  drawn  in  a  median  direction.  Immediately  beneath 
is  the  brachial  artery  in  front  of  the  intermuscular  ligament  at 
the  bone,  with  the  two  concomitant  veins.  Near  its  median 
side  is  the  middle  cutaneous  nerve. 

Below  the  middle  of  the  arm  the  basilical  vein  enters  the 
brachial  and  the  middle  cutaneous  nerve  passes  through  the 
fascia.  These  structures  can'  be  exposed  by  the  same  incision 
as  for  the  ligation  of  the  brachial  artery. 

102.  Deep  Brachial  Artery  on  the  Outer  Side  of  the  Arm 
below  the  Middle  (Figs.  55  and  56). — Incision  at  the  outer 
margin  of  the  prominence  of  the  aconseus  externus  muscle  which 
can  be  readily  located  by  being  grasped  from  behind,  passing 
downward  at  the  humerus  from  the  attachment  of  the  deltoid. 
The  body  of  the  anconseus  muscle  is  exposed  by  an  incision  be- 
hind the  strip  of  fascia  which  indicates  the  external  intermus- 
cular ligament  and  the  muscle  is  detached  from  the  latter  liga- 
ment as  far  as  the  bone.  The  artery  comes  forward  obliquely 
from  behind ;  beside  it  close  to  the  bone  is  the  radial  nerve. 


UPPER   EXTREMITY.  151 

On  the  Dorsal  Surface  of  the  Arm  above  the  Middle.     See 
Exposure  of  the  radial  nerve  at  the  same  point  (Figs.  55  and 

5(3). 

On  the  Inner  Side  of  the  Arm  in  the  Upper  Third  (Figs.  51 
and*  52).— Incision  in  the  internal  bicipital  sulcus  from  the  height 
of  the  posterior  axillary  fold  downward  through  skin  and  fascia. 
The  latter  is  divided  on  the  prominence  of  the  anconseus  longus 
muscle  behind  the  white  streak  of  the  internal  intermuscular 
hgament.  Along  the  anterior  surface  of  the  last-named  muscle 
we  proceed  toward  the  bone  behind  the  attachment  of  the  anco- 
nseus  internus  to  the  humerus.  The  first  to  appear  is  the  pro- 
funda artery  which  gives  off  a  downward  branch  to  the  internal 
head  of  the  triceps  (collateralis  media  artery). 

Somewhat  deeper  lies  the  radial  nerve  which,  descending 
from  above  over  the  tendon  of  the  latissimus,  passes  between 
the  ancongeus  internus  and  longus  muscles  toward  the  dorsal 
surface  of  the  humerus. 

The  superior  collateral  ulnar  artery  comes  within  the  same 
incision.  It  arises  some  distance  below  the  profunda  and  runs 
in  the  internal  bicipital  sulcus  behind  the  large  vascular  and 
nerve  trunks. 

The   terminal   branch  of  the   deep  brachial    (the  collateral 

radial  artery)  may  be  felt   on  the  base  of  the  external  condyle 

•  of  the  humerus  in  the  furrow  between  the  brachialis  internus 

and  brachio-radialis  and  is  to  be  there  ligated  behind  the  radial 

nerve. 

103.  Superior  Collateral  Ulnar  Arter?j.— For  its  ligation  in 
the   upper   third   of  the  upper  arm  see  Ligation  of   the  deep 

brachial. 

At  the  lower  end  the  artery  can  be  felt  on  the  dorsal  surface 
of  the  internal  condyle  and  should  be  looked  for  beside  the 
ulnar  nerve  behind  the  internal  intermuscular  ligament. 

lOi.  Inferior  Collateral  Ulnar  Artery.— The  artery  lies  on 
the  base  of  the  internal  condyle  above  the  projection  marking 


152  OPERATIVE   SURGERY. 

the  attachment  of  the  pronator  teres,  and  can  there  be  felt.  It 
is  found  after  dividing  the  tense  fascia  which  carries  a  main 
branch  of  the  median  cutaneous  nerve  and  the  junction  of  the 
basihcal  vein  with  the  median. 

105.  Median  Nerve  (Figs.  51  and  52). — See  Ligation  of  'the 
brachial  artery.  The  nerve  in  the  upper  half  lies  on  the  exter- 
nal, in  the  lower  half  on  the  internal  side  of  the  artery  and 
more  superficially. 

106.  Ulnar  Nerve  (Figs.  53  and  54). — Incision  in  a  line 
ascending  vertically  from  the  internal  condyle  at  the  anterior 
margin  of  the  belly  of  the  triceps.  Division  of  the  fascia  behind 
the  white  streak  marking  the  attachment  of  the  intermuscular 
ligament  exposes  the  body  of  the  triceps  and  at  the  same  time 
the  rather  superficial  nerve,  behind  the  above-named  ligament. 

107.  Radial  Nerve.  In  the  Loiuer  Third  of  the  Arm  (Fig. 
5Y). — Incision  at  the  anterior  margin  of  the  brachio-radialis 
muscle.  The  fascia  of  the  latter  is  divided  and  we  penetrate 
without  cutting  along  the  margin  of  the  muscle  to  the  bone. 
On  the  outer  side  of  the  brachialis  internus  muscle  lies  the 
nerve  which  toward  the  elbow  joint  is  already  divided  into  the 
superficial  and  the  deep  branch,  the  latter  resting  on  the  bone, 
and  both  are  in  front  of  the  external  intermuscular  ligament. 

Beloiv  the  Middle  of  the  Arm  on  the  Lateral  Surface  (Figs. 
55  and  56). — Incision  in  a  line  ascending  vertically  from  the 
external  condyle  at  the  lateral  margin  of  the  belly  of  the  triceps 
below  the  attachment  of  the  deltoid  to  the  humerus ;  the  triceps 
is  exposed  (external  head)  and  we  penetrate  at  its  margin 
toward  the  outer  surface  of  the  humerus,  laterally  from  the 
brachialis  internus  muscle.  The  nerve  adjoins  the  bone;  on 
its  external  radial  side  the  deep  brachial  artery  runs  parallel  to 
the  main  trunk;  behind  it  is  the  inferior  cutaneous  radial 
nerve. 

Above  the  Middle  on  the  Dorsal  Surface  (Figs.  55  and  56). — 
Incision  in  a  line  ascending  vertically  from  the  tip  of  the  olec- 


UPPER   EXTREMITY.  153 

ranon  on  the  clorsfJ  surface  of  the  arm  between  the  posterior 
margin  of  the  delt(^id  and  the  easily  detached  prominence  of  the 
long  head  of  the  triceps.  At  the  lateral  margin,  after  division 
of  the  fascia,  we  jDenetrate  toward  the  bone,  the  fingers  separat- 
ing the  two  above-mentioned  heads  of  the  triceps.  The  nerve 
lies  between  them. 

In  the  Upper  Third  on  the  Medial  Side  (Figs.  51  and  52). — 
See  Ligation  of  the  deep  brachial  artery  in  the  internal  bicipital 
sulcus. 

108.  Musculo-cutaneous  Nerve.  Beloiu  the  Middle  of  the 
Arm  (Figs.  51  and  52). — Incision  at  the  outer  margin  of  the 
belly  of  the  biceps,  the  cephalic  vein  being  preserved;  the  fas- 
cia is  divided  as  far  as  the  body  of  the  biceiDS,  and  the  finger  is 
insinuated  behind  the  inner  surface  of  the  latter.  The  nerve 
lies  under  the  thin  fascia  of  the  brachialis  internus.  Care 
should  be  taken  lest  the  outer  margin  of  the  brachialis  internus 
be  exposed  instead  of  that  of  the  biceps. 

Above  the  Middle  of  the  Arm  (Fig.  51). — Incision  in  the  in- 
ternal bicipital  sulcus.  The  body  of  the  bicej^s  is  laid  bare  and 
the  muscle  drawn  laterally.  The  nerve  lies  at  the  lateral 
margin  of  the  coraco-brachialis  muscle  through  which  it  has 
passed  so  as  to  reach  the  anterior  surface  of  the  brachialis  in- 
ternus muscle. 

d.  Elhoiu  Region. 

100.  Brachial  Artery  in  the  Bend  of  the  Elhoiv  (Figs.  51,  52, 
and  57). — Incision  midway  between  the  two  condyles,  some- 
what nearer  to  the  ulnar  side,  at  the  medial  edge  of  the  biceps 
tendon.  On  the  fascia  are  the  oblique  median  vein  and  the 
cutaneous  branches  of  the  median  cutaneous  nerve. 

Under  the  thin  fascia  the  characteristic  fibres  of  the  aponeu- 
rotic bicipital  fascia,  passing  obliquely  downward  toward  the 
ulna,  become  visible  and  are  divided  in  the  direction  of  the  cu- 
taneous  incision.     Immediately   beneath,    the   artery  lies  im- 


154 


OPERATIVE   SURGERY. 


bedded  in  the  fat  accompanied  by  two  veins.     The  biceps  tendon 
lies  laterally. 

110.  Median  Nerve  (Fig.  57),  0.5  cm.  in  a  median  direction 
at  the  lateral  margin  of  the  pronator  teres  muscle.  The 
brachialis  internus  muscle  supports  the  bundle  of  vessels  and 
nerves.     In  performing  this  ligation  we  must  remember  that 

Radial  artery  - 

Biceps  tendon 
Median  nerve 
Brachialis  internus  nius 
Brachial  artery 


Pronator  teres  muscle 

Ulnar  artery 

Fig.  57. 


the  artery  descends  from  the  internal  bicipital  sulcus,  hence  not 
to  penetrate  into  the  depth  on  the  lateral  side  of  the  biceps 
tendon.  The  brachial  artery  divides  into  the  radial  and  ulnar 
a  finger's  breadth  below  the  line  of  the  joint. 

111.  Ulnar  Nerve  (Fig.  55). — Incision  from  behind  upon  the 
base  of  the  internal  condyle ;  closely  adjoining  this  subf ascially 
lies  the  thick  nerve,  descending  between  both  attachments  of 
the  internal  ulnar  muscle  to  the  condyle,  and  passing  at  the 
olecranon  to  the  flexor  profundus. 

112.  Radial  Nerve  (Figs.  58  and  59). — At  the  elbow  joint 
the  radial  nerve,  together  with  its  deep  branch,  lies  in  the  furrow 
between  the  brachio-radialis  and  brachialis  internus  muscles. 
Incision  in  the  prolongation  of  the  external  bicipital  sulcus  at 
the  anterior  margin  of  the  belly  of  the  brachio-radialis  in  the 
bend  of  the  elbow.  The  cephalic  vein  is  drawn  down.  After 
the  fascia  is  divided  we  strike  beside  the  biceps  tendon  the 
musculo-cutaneous  nerve  which  pierces  the  fascia  so  as  to 
furnish  the  sensory  supply   to  the  radial  anterior  side  of  the 


UPPER   EXTREMITY.  15") 

forearm.  If  we  penetrate  at  the  external  margin  of  the  brachi- 
alis  internus  muscle  we  reach  on  the  bone  the  superficial  and 
deep  branch  of  the  radial  nerve,  one  behind  the  other,  and 
beneath  them  the  terminal  branch  of  the  collateral  radial  artery. 


e.  Forearm —  Volar  Surface. 

113.  The  Radial  Artery  (Figs.  58  and  59)  forms  the  straight 
continuation  of  the  brachial  artery ;  for  two-thirds  of  its  length 
it  can  be  readily  felt,  is  nowhere  covered  by  muscles,  and  only 
in  the  upper  third  is  the  brachio-radialis  drawn  over  it  by  the 
fascia.  The  direction  of  the  artery  is  determined  by  a  line  from 
the  middle  of  the  bend  of  the  elbow  to  the  point  where  the 
pulse  is  felt,  or  below  this  to  the  prominence  of  the  trapezium. 
This  line  at  the  same  time  marks  the  limit  of  the  muscular 
branches  of  the  median  and  radial  nerves  at  the  forearm. 

In  the  Lower  Third.— The  hand  being  hyperextended,  the 
incision  is  made  between  the  prominent  tendon  of  the  internal 
radial  muscle  and  the  margin  of  the  radius  or  the  tendon  of  the 
brachio-radialis.  Skin  and  fascia  are  divided;  the  artery  lies 
immediately  under  the  fascia  between  two  veins  upon  the  pro- 
nator quadratus  muscle.  The  superficial  branch  of  the  radial 
nerve  is  no  longer  visible,  as  it  passes  dorsad  under  the  tendon 
of  the  brachio-radialis  muscle  at  the  lower  third  of  the  forearm. 

I7i  the  Middle. — Incision  between  the  muscular  prominences 
of  the  radiaHs  internus  and  brachio-radialis  muscles  which  rise 
on  both  sides.  In  the  furrow  lies  the  artery  on  the  radial  at- 
tachment of  the  flexor  polHcis  longus  muscle.  On  its  radial  side 
is  the  superficial  branch  of  the  radial  nerve. 

In  the  U2oper  Half. —The  artery  lies  more  deeply  on  the 
radius  because  the  muscular  prominences  of  the  brachio-radialis 
and  the  radialis  internus  are  no  longer  present.  Incision  in  the 
distinctly  palpable  furrow  between  these  muscles.  On  the 
fascia  appear  the  cephalic  vein  and  a  thick  branch  of  the  mus- 


156  OPERATIVE   SURGERY. 

culo-cutaneous  nerve.  The  fascia  is  divided.  The  brachio- 
radialis  muscle  is  to  be  well  drawn  aside  in  a  radial  direction, 
and  the  artery  lies  deep  upon  the  radial  attachment  of  the  pro- 
nator teres.  To  the  radial  side  of,  the  artery  lies  the  superficial 
(sensory)  twig  of  the  radial  nerve. 

114.  Ulnar  Artery  (Figs.  58  and  59). — It  can  be  felt  in  the 
lower  half  because  the  greater  portion  is  not  covered  by  muscles ; 
above,  after  being  given  off  at  an  angle  from  the  brachial  ar- 
tery, it  lies  between  the  deep  muscles,  namely,  the  flexor  digi- 
torum  sublimis  and  profundus.  The  line  indicating  the  cuta- 
neous incisions  for  its  ligation  passes  from  the  internal  condyle 
of  the  humerus  to  the  prominence  of  the  pisiform  bone.  The 
line  does  not  correspond  to  the  position  of  the  artery  which 
lies  more  toward  the  median  line,  especially  above. 

In  the  Lower  Half. — Incision  in  the  furrow  between  the  in- 
ternal ulnar  muscle  and  the  flexors ;  this  furrow  is  well  marked 
in  the  vertical  prolongation  from  the  medial  margin  of  the  pisi- 
form bone  upward.  Skin  and  fascia  are  divided;  we  penetrate 
toward  the  bundle  of  flexors,  not  under  the  internal  ulnar 
muscle.  The  artery  lies  between  two  veins.  The  ulnar  nerve 
is  close  to  its  ulnar  side. 

I7i  the  Upper  Half. — Incision  in  the  above-mentioned  line  at 
the  margin  of  the  internal  ulnar  muscle  which  is  limited  by  a 
palpable  furrow.  Occasionally  the  ulnar  nerve  can  be  felt 
through  the  skin.  After  the  skin  is  divided,  we  strike  the 
basilical  vein  with  a  branch  of  the  cutaneus  medius  nerve  on 
the  fascia.  In  the  latter  the  interstice  between  the  internal 
ulnar  and  the  palmaris  longus  muscles  above,  and  the  flexor 
sublimis  below,  is  marked  by  a  distinct  white  streak.  When 
the  fascia  is  severed  along  this  streak  the  finger  penetrates 
without  cutting  alongside  the  internal  ulnar  muscle  to  the  flexor 
digitorum  profundus,  the  flexor  sublimis  being  pushed  aside. 
If  we  are  in  the  true  interstice  between  the  two  last-named 
muscles  we  come  first  upon  the  thick  ulnar  nerve.     We  pass 


UPPER   EXTREMITY. 


]57 


_  Bracliio-radialis  muscle 
Musciilo-cutaneous  nerve 
\  Inferior  collateral 
I'adial  artery 


>- Radial  nerve - 

-■ —  Brachialis  interniis  muscle 
; —  Middle  of  the  bend  of  the  elbow 


Supinator  longus  muscle 
Radial  nerve 


Pronator  teres  muscle 


Internal  ulnar  muscle. 

Flexor  sublimis  muscle. 

Ulnar  nerve. 

Ulnar  artery 


Radialis  internus  muscle - 
Median  nerve- 

Pronator  teres  muscle- 

Interosseal  artery - 

Interosseal  nerve' 

Flexor  sublimis  muscle' 

Radial  artery" 


Radial  ner\e 

Supinator  longus  (brachio-radialis)  muscle 
RadiaUs  internus  muscle 


Ulnar  nerve. 

Tendon  of  internal  ulnar  muscle 

Ulnar  artery 

Radial  artery 

Tendon  of  radialis  internus  muscle 

if-jMjJ Tendon  of  palmaris  longus  muscle     The  two  radial  i 

|f;iZZ  Ramus  palmaris  ^ems  ( 

^^^, ^Ulnar  artery  Ulnar  nerve 

-Trapezium  Ospisiforme 

Flexor  pollicis  brevis  Ulnar  artery 

muscle  Tendon  of  flexor  sublimis 

Median  nerve. 

Supei-flcial  i:)almar  arch 

Process  of  unciform  bone 

Ulnar  nerve 


'--'frr-V- Tendon  of  flexor  digiti  II. 

.■V~Deep  palmar  arch 

<^..^  \  Median  nerve, 

'^<^^  1  thumb  branch 

■  ,^,>^ Adductor  pollicis  muscle 

First  lumbricalis  muscle 


t 


f¥: 


k.-^ 


Ulnar 
nerve 


Digitalis  ^'olaris  artery" 


1  11^ 


Fig.  5!). 


Figs.  58  and  59.— Arteries  and  Nerves  of  the  Forearm  aud  Hand. 


158  OPERATIVE   SURGERY. 

laterally  in  front  of  the  nerve  because  it  supplies  branches  to 
the 'muscles  beneath  (internal  ulnar  and  flexor'  profundus). 
Toward  the  upper  end  the  artery  lies  more  medially  from  the 
nerve. 

115.  Interosseal  Artery  (Figs.  58  and  59). — This  branch  of 
the  ulnar  artery  can  be  exposed  through  the  same  incision  as 
that  for  the  ulnar  artery  in  the  upper  third,  by  passing  in  a 
median  direction  from  the  flexor  profundus  muscle  until  the 
median  nerve  with  its  branches  is  found.  Below  the  latter  the 
interosseal  artery  passes  tov/ard  the  interosseous  ligament  be- 
tween flexor  profundus  and  flexor  pollicis  longus.  Upon  it  lies 
the  interosseous  branch  of  the  median  nerve.  The  interosseal 
artery  can  also  be  exposed  by  the  incision  for  the  interosseus 
nerve  just  named  (see  Fig.  58). 

116.  Median  Nerve  (Figs.  58  and  59).  .Above  the  Wrist 
Joint. — Incision  through  the  skin  between  the  tendon  of  the 
internal  radial  muscle  and  the  palmaris  longus ;  close  above  the 
wrist  joint  we  expose  the  point  of  perforation  of  the 

117.  Cutaneus  palmaris  nerve  (from  the  median) ;  the  upper 
part  of  the  latter,  together  with  the  trunk  of  the  nerve,  lies  under 
the  fascia  of  the  deeper  muscular  layer. 

In  the  Middle. — Incision  in  the  middle  of  the  forearm  at  the 
radial  end  of  the  internal  radial  muscle,  in  the  interstice  toward 
the  brachio-radialis  muscle.  The  internal  radial  muscle  is 
drawn  toward  the  ulna.  In  the  furrow  appears  first  the  radial 
artery  and  at  its  ulnar  side  we  strike  the  flexor  digitorum  sub- 
limis  muscle,  whose  radial  margin  is  laid  bare  and  drawn  vig- 
orously to  the  ulnar  side.  The  thick  nerve  becomes  visible  on 
the  digitorum  profundus  muscle,  accompanied  by  an  artery. 

In  the  Upper  Third. — Incision  at  the  radial  margin  of  the 
internal  radial  muscle  in  the  deep  furrow  toward  the  brachio- 
radialis.  Toward  the  ulna,  beside  the  radial  artery  there  ex- 
posed, we  strike  the  pronator  teres  muscle  which  is  drawn  up- 
ward or  divided. 


UPPER   EXTREMITY.  159 

The  nerve  is  now  laid  bare,  above  the  point  where  it  passes 
under  the  teildon  of  the  flexor  digitorum  sublimis  muscle ;  be- 
low, the  radial  attachment  of  this  muscle  must  be  severed  from 
its  main  body  so  that  the  latter  can  be  drawn  toward  the  ulna. 
The  median  nerve  rests  on  the  flexor  profundus.  The  same 
incision  exposes: 

118.  Tlie  Interosseus  Nerve  (from  the  Median).  It  lies  more 
deeply  on  the  interosseous  ligament,  in  the  furrow  between  the 
flexor  digitorum  profundus  and  flexor  poUicis  longus  muscles. 
The  interosseus  nerve  supplies  the  last-named  muscle  and 
farther  down  the  pronator  quadratus.  Beneath  the  interosseus 
nerve  lies  the  interosseal  artery  (branch  of  the  ulnar  artery). 

Deep  Incisions  on  the  Volar  Side  of  the  Forearm. — Bearing 
in  mind  the  course  of  the  radial  artery  and  nerve  on  the  one 
side,  and  the  interosseal  artery  and  nerve  on  the  other  side,  we 
can  penetrate  on  the  radial  side  of  the  median  throughout  the 
entire  length  to  the  interosseal  ligament  and  the  radius  without 
danger  of  causing  any  serious  incidental  injury,  since  this  is 
the  border  line  between  the  two  nerve  distributions.  On  the 
interosseal  ligament  we  not  rarely  flnd  deep  abscesses  due  to 
extension  of  inflammations  of  the  tendinous  sheaths  of  the 
hand,  requiring  free  and  deep  incisions. 

/.  Forearm — Dorsal  Surface. 

119.  Deep  Branch  of  the  Radial  Nerve  (Figs.  60  and  61). 
— Incision  on  the  dorsal  surface  at  the  margin  of  the  -eminence 
of  the  brachio-radialis  and  the  radiales  externi,  extending  be- 
tween these  muscles  and  the  extensor  digitorum  communis  in  a 
line  vertically  downward  on  the  radial  side  from  the  head  of 
the  radius  which  can  always  be  distinctly  felt.  The  fascia  is 
divided  and  the  oblique  attachment  of  the  extensor  digitorum 
communis  is  drawn  backward  and  that  of  the  radialis  externus 
longus  muscle  forward.     The  characteristic  oblique  fibres  of  the 


160  OPERATIVE   SURGERY. 

supinator  brevis  muscle  are  thus  laid  bare.  When  these  are 
divided,  the  nerve  is  exposed  a  thumb's  breadth  below  the  joint, 
descending  from  the'  volar  to  the  radial  and  dorsal  side.  Some 
of  its  longer  branches  pass  between  the  extensor  communis  and 
radiales  externi  on  the  dorsal  surface  of  the  radius  to  the  ten- 
dons of  the  abductor  and  the  flexors  of  the  thumb. 

Incisions  on  the  dorsal  surface  of  the  forearm,  whose  muscles 
are  supplied  by  the  radius,  may  be  made  over  the  whole  limb 
along  the  ulna ;  also  along  the  radial  margin  of  the  external 
ulnar  muscle  which  adjoins  the  ulna  and  receives  its  nerve  sup- 
ply high  up.  On  the  radial  side  incisions  are  admissible  in  a 
line  from  the  head  of  the  radius  to  the  styloid  process  of  this 
bone,  ^'.e.,  from  the  point  where  the  radial  nerve  pierces  the 
supinator  brevis,  downward  between  the  external  radial  muscles 
»and  the  extensor  digitorum  communis.  In  the  lower  half, 
where  the  external  radial  muscles  pass  under  the  oblique  thumb 
muscles,  the  incisions  must  be  made  upon  the  radius,  between 
the  thumb  muscles  and  the  tendon  of  the  brachio-radialis  mus- 
cle. In  an  ulnar  direction  from  the  thumb  muscles,  in  the 
lower  half  of  the  forearm,  incisions  can  be  made  between  all 
the  tendons  of  the  dorsal  surface,  as  no  larger  vessels  and  nerves 
need  be  feared  there. 

g.   Wrist  Joint — Volar  Side. 

120.  Ulnar  Artery  at  the  Pisiform  Bone  (Figs.  58  and  59). 
— Its  pulsation  can  always  be  distinctly  felt  here.  Furnishing 
the  main  supply  of  the  superficial  volar  arch,  the  artery  requires 
ligation  in  hemorrhages  at  this  point  which  resist  other 
measures. 

Incision  5  mm.  in  a  radial  direction  from  the  distinctly  pal- 
pable prominence  of  the  pisiform  bone,  extending  through  the 
skin  and  the  common  volar  ligament  of  the  wrist.  The  artery 
lies  in  a  cushion  of  fat  on  the  ligamentum  carpi  volare  pro- 


UPPER  EXTREMITY,  161 

prium.     The    thick    uhiar   nerve  adjoins    it    toward  the   pisi- 
form bone. 

121.  Median  Nerve  (Figs.  58  and  59). — Incision  in  the  palm 
where  the  thenar  and  hypothenar  eminences  join,  extending 
through  the  skin  and  the  fascia  of  the  thick  ligamentum  carpi 
volare  proprium.  The  nerve  lies  flat  on  the  common  mucous 
sheath  of  the  flexors  and  divides  into  two  terminal  branches: 
the  first  going  to  the  muscles  of  the  thenar  excepting  the  ad- 
ductor, and  to  three  finger  margins  at  the  thumb  and  index 
finger;  the  second,  to  two  lumbricales  and  four  more  finger 
margins. 

Ji.   The  Hand — Dorsal  Side. 

On  the  dorsum  of  the  hand  a  line  from  above  the  centre  of 
the  middle  finger  upward  to  the  wrist  divides  the  distribution 
of  the  radial  and  ulnar  nerves.  The  arterial  dorsal  arch  and  its 
intermetacarpal  twigs  are  relatively  unimportant  vessels.  In 
incisions,  therefore,  the  tendons  require  the  most  attention. 
The  extensor  tendons  at  the  wrist  joint  have  to  a  great  extent 
separate  mucous  sheaths  down  to  the  middle  of  the  metacarpus. 

122.  Radial  Artery  on  the  Dorsum  of  the  Hand  (Figs.  60 
and  (11). — Main  supply  of  the  deep  volar  arch.  Incision  at  the 
most  posterior  palpable  end  of  the  intermetacarpal  space  between 
thumb  and  index  finger,  along  the  ulnar  side  of  the  tendon  of 
the  extensor  pollicis  longus.  On  the  fascia,  twigs  of  the  dorsal 
branch  of  the  radial  nerve  and  the  cephalic  vein  must  be  pre- 
served. Passing  between  the  bases  of  the  above-named  meta- 
carpal bones  we  strike  the  artery  on  the  transverse  ligament 
uniting  them.  Peripherally  from  the  artery  is  the  first  interos- 
seus  muscle.  A  common  digital  branch  for  the  index  finger 
and  thumb,  given  oif  by  the  artery,  is  very  apt  to  be  mistaken 
for  it. 

123.  Badial  Artery  on  the  Trapezium  (Figs.  60  and  61). — 

Longitudinal  incision    from    the    lower  end    of    the  radius   to 
11 


162  OPERATIVE   SURGERY. 

the  base  of  the  first  metacarpal  bone,  between  the  tendons 
of  the  extensor  poUicis  longus  and  brevis  muscles.  In  the  sub- 
cutaneous tissue  we  must  preserve  the  cephalic  vein  running 
parallel  to  the  tendons  and  the  dorsal  radial  nerve  which  can 
be  felt  upward  on  the  radial  side  of  the  radius.  In  an  oblique 
direction  from  the  course  of  these  structures  and  the  tendons  the 
artery  lies  under  the  fascia  upon  the  joint  capsule  and  bone. 

Dorsal  Branch  of  the  Ulnar  Nerve  (Figs.  60  and  62). — This 
can  be  distinctly  felt  on  the  ulnar  side  of  the  unciform.  It  is 
exposed  by  a  longitudinal  incision  extending  from  the  lowest 
point  of  the  ulna  downward  on  the  ulnar  side,  and  lies  upon  or 
in  the  fascia,  passing  dorsad  under  the  internal  ulnar  muscle. 

Dorsal  Branch  of  the  Radial  Nerve  (Figs.  60  and  61).  — This 
is  exposed  by  the  same  incision  as  that  for  the  radial  artery  on 
the  trapezium  (which  see).  It  can  be  felt  through  the  skin  on 
the  radial  side  of  the  lower  end  of  the  radius,  after  it  has  taken 
a  dorsal  direction  at  the  lower  third  of  the  forearm  under  the 
tendon  of  the  brachio-radialis  muscle. 

i.   The  Palm  of  the  Hand. 

In  the  palm  the  vessels  and  nerves  run  in  the  direction  of 
the  interstices  of  the  fingers,  -the  tendons  in  the  direction  of  the 
fingers,  all  under  the  tense  superficial  palmar  fascia. 

The  latter  with  its  processes  (ligamenta  vaginalia)  accompa- 
nies the  tendons  to  the  fingers,  but  between  them  ends  in  curves, 
■concave  below,  which  are  attached  by  septa  to  the  ligamenta 
capitulorum  metacarpi,  so  as  to  separate  the  tendons  with  the 
muscles  from  the  vessels  and  nerves. 

Above  the  muscles  of  the  thumb  and  the  hypothenar  emi- 
nence the  superficial  layer  of  the  palmar  fascia  coalesces  with 
the  deep  layer. 

Under  the  palmar  fascia  the  bundle  of  flexor  tendons  with 
the  lumbrical  muscles  lies  in  a  mucous  sheath  which  extends 


UPPER   EXTREMITY. 


1G3 


'^.M 


mmi 


^m%k 


Brachio-radialis  muscle 

( Deep  branch     Extensor     j 

-■I  of  the  radial     digitorum     V 

I        nerve       communis  m. ) 

Deep  branch  of  the  radial  nerve 
Supinator  brevis  muscle 


iii 


Wl 


Extensor  pollieis  longus  muscle 
•  Dorsal  branch  of  the  ulnar  nerve 

'Radial  artery  (trapezium) 

^Radial  artery  (on  the  dorsum) 
Radial  artery 


Radial  nerve 
Tendon  of  extensor 
pollieis  longus  muscle 

Dorsal  metacarpal  artery 


Fig.  60. 


Fia.  61. 


Figs.  60  and  61.— Dorsal  Radial  Artery,  Radial  Nerve  with  Branches,  Dorsal  Ulnar  Nerve. 


164 


OPERATIVE   SURGERY. 


from  the  ends  of  the  forearm  bones  to  the  base  of  the  metacar- 
pus. The  flexor  poUicis  longus  has  a  separate  sheath.  Under 
the  bundle  of  tendons  is  the  thinner  deep  fascia,  covering  the 
interosseus  muscles  and  the  bones. 

The  guiding -points  around  the  wrist  are  the  following:  The 
OS  pisiforme  with  the  attachment  of  the  internal  ulnar  nerve, 
the  proximity  of  the  palpable  ulnar  vessels  and  nerve  on  its 


Tendon  of  the  interosseous  muscle 


j  Ulnar  extensor  tendon  for  the 
terminal  phalanx 

Digital  artery 


Digital  nerve 

Digital  artery 
Digital  nerve 


Ulna 

Ulnar  nerve  (dorsal  cutaneous  branch; 


Fig.  62. 


radial  side ;  on  the  ulnar  side  of  the  wrist  under  the  os  pisiforme 
the  projecting  body  of  the  unciform;  a  thumb's  breadth  down- 
ward and  somewhat  radially  from  the  os  pisiforme  in  the  palm 
the  process  of  the  unciform,  under  which  are  the  deep  palmar 
arch  and  the  deep  branch  of  the  ulnar  nerve;  immediately 
above  the  thenar  the  prominence  of  the  trapezium  across  which 
passes  the  branch  of  the  radial  artery  to  the  superficial  volar 
arch.  The  wrist  joint  has  for  its  fascia  a  transverse  thickening 
of  the  common  fascia  (ligamentum  carpi  commune  dorsale  and 
volare)  and  a  deep  fascia  on  the  joint  capsule;  besides,  on  the 
palm,  the  stout  ligamentum  carpi  volare  proprium  which  keeps 
the  tendons  in  the  groove  of  the  carpal  bones  and  from  which 
springs  a  portion  of  the  thumb  muscles. 

126.  Superficial  Volar  Arch  (Figs.  58  and  59). — Longitu- 
dinal incision  from  the  junction  of  the  thenar  and  hypothenar 
eminences,  extending  toward  the  fourth  finger ;  its  middle  should 
be  in  the  transverse  line  of  the  fold  between  the  hand  and  the 
abducted  thumb.     At  the  intersecting  point  of  the  two  lines  the 


UPPER   EXTREMITY.  105 

arch  can  be  felt  pulsating.  After  dividing  the  skin  and  the 
stout  tendinous  palmar  fascia,  the  arch  (imbedded  in  fatj  be- 
comes at  once  visible  under  the  smooth  inferior  surface  of  the 
latter.  The  arch  forms  the  continuation  of  the  ulnar  artery  and 
here  begins  to  curve  toward  the  side  of  the  thumb.  The  thick 
common  digital  arteries  spring  from  its  distal  portion.  The  arch 
rests  upon  the  longitudinal  digital  branches  of  the  ulnar  (these 
become  visible)  and  median  nerves.  If  the  artery  cannot  be 
found,  the  ulnar  artery  must  be  ligated  at  the  os  pisiforme. 

The  ulnar  nerve  is  to  be  exj)osed  by  the  same  incision ;  the 
superficial  branch  passes  downward  over  the  palpable  process  of 
the  unciform ;  the  deep  branch  passes  into  the  depth  between 
the  abductor  and  flexor  brevis  at  the  ulnar  side  of  the  process 
and  supplies  the  flexor  brevis  and  opponens  digiti  minimi,  two 
lumbricals,  and  all  the  interossei  with  the  adductor  pollicis. 

127.  Deep  Volar  Arch  (Figs.  58  and  59). — This  arch,  con- 
trary to  the  superficial,  springing  mainly  from  the  radial  artery, 
gives  off  large  vessels  to  the  lateral  margins  of  the  hand,  while 
its  intermetacarpal  branches  are  small.  Incision  in  the  fold  of 
the  thenar  eminence,  passing  from  its  upper  junction  with  the 
hypothenar  eminence  toward  the  index  finger.  The  centre  of 
the  incision  corresponds  to  the  middle  of  the  thenar  eminence. 
After  dividing  the  skin  and  palmar  fascia  (and  eventual  ligation 
of  the  superficial  arch)  we  enter  at  the  radial  margin  of  the 
lumbrical  muscle  beside  the  flexor  tendons  of  the  index  finger. 
Then  appears: 

128.  The  radial  branch  of  the  median  nerve  which  is  drawn 
toward  the  radius  together  with  the  superficial  muscles  of  the 
thenar  (flexor  brevis  and  opponens).  In  the  depth  we  see  the 
transverse  fibres  of  the  broad  adductor  pollicis  muscle.  Directly 
beneath  the  muscle,  which  is  divided,  the  transverse  artery 
appears  on  the  deep  fascia,  somewhat  nearer  to  the  wrist  than 
the  superficial  arch. 

129.  The  common  digital  arteries  are  to  be  exposed  under 


166  OPERATIVE   SURGERY. 

the  fascia  between  the  interdigital  fold  and  the  superficial  arch, 
by  corresponding  longitudinal  incisions.  Beside  them,  rising 
toward  the  surface,  are  the  large  digital  branches  of  the  ulnar 
and  median  nerves. 

j.  Fingers. 

130.  The  main  portion  of  the  subcutaneous  soft  parts  on  the 
fingers  consists  of  the  tendons  which  leave  only  the  narrow 
lateral  surfaces  free.  The  flexor  tendons  lie  upon  the  perios- 
teum. On  the  middle  phalanx  the  tendon  of  the  deep  flexor 
passes  through  that  of  the  superficial.  The  latter  is  semilunar 
in  section  (convex  toward  the  bone),  the  former  cylindrical. 

The  two  crura  of  the  flexor  sublimis  pass  around  the  tendon 
of  the  flexor  profundus  and  are  attached  to  the  lateral  surfaces 
of  the  middle  phalanx.  The  flexor  profundus  muscle,  after 
passing  through  the  fissure  of  the  flexor  sublimis,  likewise  be- 
comes flatter  and  is  attached  to  the  base  of  the  terminal  phalanx. 
As  far  as  the  base  of  the  terminal  phalanx  the  tendons  are  sur- 
rounded by  a  tubular  prolongation  of  the  superflcial  palmar 
fascia,  the  ligamenta  vaginalia,  and  from  the  condyles  of  the 
metacarpal  bones  downward  they  are  invested  with  closed  mu 
cous  sheaths  which  at  the  thumb  and  little  flnger  approach  the 
mucous  sheath  of  the  palm  -and  often  communicate  with  ^"t. 
From  the  bones  and  joint  capsules  vincula  tendinum  pass  to  the 
under  surface  of  the  tendons. 

The  extensor  tendon  of  the  flngers  is  attached  to  the  base  of 
the  flrst  phalanx  by  isolated  fibres  and  divides  into  three  crura ; 
the  central  one  is  joined  under  the  two  lateral  ones  by  the  fibres 
of  the  lumbrical  and  interossei  muscles  (the  flexor  of  the  first 
and  extensors  of  the  terminal  phalanges),  and  they  are  attached 
together  at  the  base  of  the  middle  phalanx.  The  lateral  crura 
descend  laterally  at  the  upper  interphalangeal  joint,  pass  again 
to  the  dorsum,  and  are  attached  at  the  base  of  the  terminal 
phalanx ;  all  the  extensor  tendons  are  fiat,  like  fasciae.     On  the 


LOWER   EXTREMITY.  167 

thumb  the  extensor  brevis  muscle  ends  on  the  base  of  the  first 
phalanx ;  the  extensor  longus,  situated  somewhat  to  the  dorso- 
ulnar  side,  ends  with  its  three  crura  at  the  base  of  the  terminal 
phalanx. 

As  the  ungual  phalanx  has  tendons  attached  only  at  the 
base,  the  choice  for  incisions  there  is  free ;  they  may  be  made 
median  or  lateral  according  to  indications. 

The  digital  arteries  and  nerves  (Fig,  62)  pass  in  part  at  the 
middle  phalanx  from  the  volar  to  the  dorsal  side ;  in  the  incisions 
on  the  middle  phalanx  regard  is  to  be  had  mainly  for  the  larger 
vessels  and  nerves  beside  the  volar  tendon,  hence  lateral  inci- 
sions should  be  placed  nearer  the  dorsum. 

On  the  first  phalanx  the  two  volar  and  two  dorsal  digital 
arteries  and  nerves  are  well  developed,  but  here,  too,  the  main 
vessels  pass  beside  the  volar  tendons  (the  nerves  on  the  volar 
side  of  the  arteries  and  veins),  so  that  incisions  here  may  be 
purely  lateral.  Only  at  the  base  of  the  first  phalanx  should  the 
deeper  incisions  deviate  toward  the  palm  after  division  of  the 
skin,  owing  to  the  broad  tendinous  attachment  of  the  lumbrical 
and  interossei  muscles.  Where  choice  is  free  it  is  better  to 
make  incisions  on  the  ulnar  than  the  radial  side,  because  of  the 
short  flexors  of  the  first  phalanx  the  lumbricals  approach  from  the 
radial  side. 

S.  Lower  Extremity. 
Gluteal  Region. 

Branches  of  the  Hypogastric  Artery. 

131.  Superior  Gluteal  Artery  (Fig.  63). — The  point  for  its 
ligation  can  be  marked  through  the  skin,  by  feeling  at  the  level 
of  the  upper  end  of  the  intergluteal  furrow  and  at  the  upper 
margin  of  the  belly  of  the  glutaeus  maximus  the  upper  circum- 
ference of  the  great  sciatic  foramen. 

Incision  in  the  direction  from   the  posterior  superior  iliac 


168  OPERATIVE   SURGERY. 

spine  to  the  tip  of  the  great  trochanter,  corresponding  to  the 
upper  two-thirds  of  this  line.  Division  of  the  skin,  fascia,  and 
the  thick  glutseus  maximus,  parallel  to  its  fibres.  After  sever- 
ing the  fascia  of  the  glutseus  medius,  this  muscle  is  laid  bare, 
without  cutting,  at  its  lower  margin  and  drawn  up.  Under  it 
the  finger  feels  the  upper  circumference  of  the  great  sciatic  fo- 
raraeu.  Here,  above  the  upper  margin  of  the  pyriformis  mus- 
cle, the  thick  artery  passes  directly  backward  from  the  pelvis 
and  at  once  gives  off  large  branches  (the  main  branch  going 
laterally).  Beside  it  the  superior  gluteal  nerve  (Fig.  63)  leaves 
the  pelvis,  passing  between  and  supplying  the  glutseus  medius 
and  minimus,  and  following  the  main  branch  of  the  artery  lat- 
erally to  the  tensor  fasciae  latse  muscle. 

132.  Inferior  Gluteal  (Sciatic)  Artery  (Fig.  63). — Incision 
in  the  direction  from  the  inferior  posterior  iliac  spine  to  the  base 
of  the  great  trochanter,  parallel  to  the  incision  for  the  ligation 
of  the  superior  gluteal  artery;  the  medial  two -thirds  of  the  line 
given  ,are  used.  Division  of  the  skin  with  the  fatty  subcuta- 
neous tissue,  the  fascia,  and  the  fibres  of  the  thick  glutseus 
maximus  muscle.  Under  the  latter  the  posterior  margin  of 
the  pyriformis  muscle  becomes  visible  and  is  laid  bare  with  the 
fingers ;  under  its  medial  end  the  artery  emerges  accompanied 
by  the  nerve  of  the  same  name  which,  like  the  artery,  gives  off 
thick  branches  to  the  glutaeus  maximus.  The  point  where  the 
artery  passes  out  of  the  pelvis  is  found  by  the  spine  of  the  is- 
chium and  the  spinoso-sacral  ligament,  extending  in  a  median 
direction  from  its  point.  Above  the  spine  we  feel  the  lower  mar- 
gin of  the  great  sciatic  foramen  over  which  the  artery  emerges. 

133.  The  posterior  femoral  cutaneous  nerve  passes  in  the 
direction  of  the  continuation  of  the  arterial  trunk  (Fig.  72). 
Deeper  and  more  laterally,  directly  upon  the  bone,  lies  the 
easily  palpable  main  trunk  of  the 

134.  Sciatic  nerve  which  descends  over  the  base  of  the  spine 
of  the  ischium  and  the  obturator  internus  muscle. 


LOWER   EXTREMITY. 


169 


Lumbo-dorsal  fascia 
Sacro-luinbalis  muscle 
Serratus  posticus  infe 

rior  uiuscle  j 

Latissimus  dorsi  muscle 

Lumbo-costal  fascia 


Glutaeus  maxunus  m 

Glutaeus  medius  m. 

Super'r  gluteal  artery 

Pyriformis  muscle 

Tip  of  the  great  I 
trochanter      ) 


Base  of  the  great 

trochanter       j    M,\Wm 

m 
/if* 


Latissimus  dorsi  muscle 
Twelfth  intercostal  nerve 
Quadratus  lumborum  m. 
First  lumbar  nerve 
Transverse  abdominal  m. 
Ext'l  abdom'l  oblique  m. 
IntT  abdom'l  oblique  m. 
Posterior  super"r  spine 
of  the  iMum 

(  Posterior  inferY  spine 
of  the  ilium 


j  Glutaeus  maximus 
I  muscle 

Int'l  pudendal  artery 
Infl  pudendal  nerve 
Pyriformis  muscle 
Sciatic  artery 
Sciatic  nerve 

Posterior  cutaneus 
I        femoris  nerve 
Obturator  internus 
m.  (with  gemelli) 


Fig.  03.— Nephrotouiy.    Gluteal  and  sciatic  arteries. 


170  OPERATIVE   SURGERY 

135.  Internal  Pudendal  Artery  (Fig.  68). — Incision  as  for 
the  ligation  of  the  inferior  gluteal  artery.  The  vessel  lies 
medially  of  and  under  the  inferior  gluteal  artery  on  the  posterior 
surface  of  the  spine  of  the  ischium,  accompanied  by  the  internal 
pudendal  nerve  which  rests  upon  it.  It  may  be  recognized  by 
its  re-entering  the  pelvis  below  the  spine. 

Inguinal  Region. 

136.  External  Hiac  Artery  (Figs.  64  and  65). — Incision 
parallel  to  and  immediately  above  the  middle  third  of  Poupart's 
ligament.  Division  of  the  skin  and  the  well- developed  super- 
ficial fascia.  The  superficial  epigastric  artery  which  ascends 
vertically  in  the  latter  must  be  severed.  Division  of  the  apo- 
neurosis of  the  external  abdominal  oblique.  The  internal 
oblique  and  the  transversus  are  lifted  with  the  handle  of  the 
scalpel  from  the  ascending  groove  of  Poupart's  ligament,  then 
the  thick  transverse  fascia  is  cut.  The  artery  lies  under  the 
middle  of  Poupart's  ligament,  imbedded  in  adipose  tissue  with 
glands ;  inward  from  it  is  the  vein,  outward  the  fascia  of  the 
psoas  muscle.  Between  the  latter  and  the  margin  of  the  inter- 
nal iliac  muscle,  which  lies  about  2  cm.  laterally  from  the 
artery  in  the  depth,  is  the  cjural  nerve.  Upon  the  artery  are 
the  thin  crural  branches  of  the  genito-crural  nerve  which  supply 
the  medial  anterior  side  of  the  skin  of  the  thigh  in  the  upper 
third. 

The  branches  of  the  external  iliac  artery,  namely,  137.  In- 
ferior epigastric  and  138.  Circumflexa  ilii  artery,  can  be  ex- 
posed by  the  same  incision  as  the  external  iliac,  at  their  point 
of  origin  above  Poupart's  ligament,  under  the  abdominal  mus- 
cles and  under  the  transverse  fascia. 

139.  Inferior  Epigastric  Artery  at  the  Anterior  Abdominal 
Wall  (Fig.  36). — Incision  two  or  three  fingers'  breadth  above 
Poupart's  ligament,  parallel  to  its  medial  third,  through  skin, 


LOWER  EXTREMITY. 


171 


Internal  iliac  muscle 

Poupart's  ligament 
Psoas  muscle 

(  Fascia  of  external  abdominal 
■(       oblique  muscle 
External  iliac  artery 
Superficial  epifiastric  artery- 
External  iliac  vein 

Internal  oblique  and  transverse  muscle 
Inferior  epif;aslric  artery 

y-r-T) .*  S'lpt-rfi'-ial  epi-      internal  cir-  / 

iff^/         \  gastric  artery        cumflex  and  - 

Ir    ''^^  .      ■  obturator  art.  ^ 

M*V^=^  Femoral  veui 

-yj'luit  —Internal  circumflex  artery 

Pectineus  muscle 


Point  midway  between 
symiiliysis  and  ant. 
sup.  iliac  spine 

Incision  for  ex- 
ternal iliac 
artery 


Femoral  artery- 
Femoral  vein 
Adductor  longus  muscle 
Sartorius  muscle 

Internal  saphenus  nerve 


Sartorius  muscle 

Femoral  artery- 


Femoral  vein 

Internal  saphenus  nerve 

Vastus  intemus  muscle 

Tendon  of  adductor  magnus  muscle 


Superficial  artery  of  the  knee  joint 
Tendon  of  adductor  magnus  muscle 
Vastus  internus  muscle 

Internal  condyle  of  the  femur 


Fig.  c: 


FiG.  G4. 


Figs.  01  and  0.5.— External  Iliac  Artery  and  Femoral  Artery  with  its  Branches. 


172  OPERATIVE   SURGERY. 

superficial  fascia,  the  thick  fascia  of  the  external  oblique  and 
that  of  the  internal  oblique  which  can  at  least  be  partly  sepa- 
rated from  it.  The  margin  of  the  rectus  abdominis  is  laid  bare. 
Beneath  this,  covered  by  a  very  thin  layer  of  connective  tissue 
(transverse  fascia),  we  recognize  the  subserous  fat,  and  upon  it 
the  artery  ascending  obliquely  from  without  and  below  to  the 
wall  of  the  rectus.  The  transverse  fascia,  which  below  lies 
upon  and  above  under  the  artery,  here  exhibits  what  is  known 
as  the  plica  semilunaris. 

140.  Circumjlexa  Ilii  Artery  (Fig.  TO). — Incision  at  the 
outer  third  of  Poupart's  ligament.  Division  of  skin,  superficial 
fascia,  the  muscular  layers  in  which  the  branches  of  the  ilio- 
inguinal nerve  are  exposed,  and  the  thick  transverse  fascia. 
The  peritoneum  being  slightly  pushed  up  with  the  fingers,  the 
artery  is  found  parallel  to  Poupart's  ligament  on  the  internal 
iliac  fascia;  obliquely  outward  and  downward  it  is  crossed  by 
the  lateral  cutaneous  femoral  nerve. 

141.  Aorta  and  Common  Iliac  Artery  (Figs.  <dQ  and  67). — 
At  the  level  of  the  umbilicus  or  the  line  connecting  the  anterior 
superior  iliac  spines  the  aorta  divides  into  the  two  common  iliac 
arteries  which  run  vertically  to  the  middle  of  a  line  connecting 
the  anterior  superior  iliac  spine  with  the  symphysis  pubis, 
downward  along  the  medial  psoas  margin.  The  upper  third  of 
the  line  corresponds  to  the  common  iliac,  the  lower  two-thirds 
to  the  external  iliac. 

Incision  beginning  in  front  of  the  tip  of  the  eleventh  left 
rib,  passing  obliquely  downward  and  forward  within  two  fin- 
gers' breadth  above  the  middle  of  Poupart's  ligament.  Division 
of  skin,  superficial  fascia,  and  the  thick  muscular  layers  of  the 
abdominal  wall  with  the  characteristic  course  of  the  fibres  of 
the  obliquus  externus,  internus,  and  transversus.  Between  the 
last  two  the  thick  branches  of  the  lumbar  vesels  and  nerves  are 
exposed.  Division  of  the  well -developed  transverse  fascia  and 
the  subserous  fat.     Detachment  of  the  peritoneum  first  down- 


LOWER   EXTREMITY.  173 

ward  and  then  backward  of  the  internal  iliac  fascia  (which 
covers  the  internal  iliac  muscle  with  shining  transverse  fibres) 
as  far  as  the  inner  margin  of  the  psoas  muscle  and  thence  up- 
ward to  the  anterior  surface  of  the  spinal  column.  The  lateral 
cutaneous  femoral  nerve  passes  obliquely  outward  and  down- 
ward on  the  iliac  fascia ;  above  it  are  the  vasa  circumflexa  post, 
ilii.     With  the  peritoneum, 

142.  The  internal  spermatic  vessels  which  pass  to  the  poste- 
rior inguinal  ring  are  detached.  In  a  median  direction,  above 
the  bifurcation  of  the  common  iliac  artery, 

1-43.  The  ureter  descends  nearly  vertically  into  the  pelvis 
and  is  likewise  detached.  Alongside  of  the  common  iliac 
artery  the  genito-crural  nerve  descends  and  bends  over  the 
anterior  surface  of  the  external  iliac  artery.  On  the  anterior 
surface  of  the  spinal  column  the  aorta  divides.  Above  it  a 
very  large  vessel, 

14"!.  The  inferior  mesenteric  artery,  descends  vertically  and 
is  to  be  detached  likewise  with  the  peritoneum.  About  3  cm. 
above  the  bifurcation  of  the  aorta  a  lumbar  artery  branches  off 
laterally. 

145.  Hypogastric  Artery  (Figs.  QQ  and  67). — Incision  as  for 
the  common  iliac  artery.  The  vessel  originates  at  the  inner  mar- 
gin of  the  psoas  muscle,  in  front  of  the  sacro-iliac  synchondrosis, 
from  the  division  of  the  common  iliac  artery.  It  turns  inward 
and  downward  into  the  lesser  pelvis  at  the  point  where  the 
ureter  crosses  the  anterior  surface  of  the  common  iliac  artery. 

For  the  branches  of  the  hypogastric  artery  see  the  Gluteal 
region. 

146.  Obturator  Artery  and  Nerve  (Fig.  61). — The  artery  is 
a  branch  of  the  hypogastric.  Incision  as  for  the  ligation  of  the 
internal  circumflexa  femoris,  beginning  a  finger's  breadth  in  a 
median  direction  from  the  middle  of  Poupart's  ligament  and 
extending  vertically  downward.  Division  of  skin,  superficial 
fascia,  and  tense  fascia  lata.     The  great  saphenous  vein  resting 


174 


OPERATIVE    SURGERY. 


upon  the  latter  is  drawn  laterally  downward,  at  the  inner  mar- 
gin of  the  femoral  vein  the  fascia  pectinea  is  severed,  and  the 
outer  margin  of  the  pectineal  muscle  is  laid  bare  and  drawn 
down  in  a  median  direction  and  eventually  nicked  transversely 
above. 


Superficial  fascia 

External  abdominal  oblique  muscle 
Internal  abdominal  oblique  muscle 
Transverse  muscle  and  fascia 


External  abdominal  oblique 

muscle 
Fascia  of  the  external  ab- 
dominal oblique  muscle 


Fig.  66. 


LOWER    EXTREMITY. 


175 


Under  the  upper  attachment  of  the  muscle  and  below  the 
horizontal  ramus  of  the  pubic  bone  the  finger  feels  the  obturator 
foramen  from  which  emerges  the  artery  with  the 

147.  Obturator  nerve,  over  the  upper  margin  of  the  external 
obturator  muscle,  whose  fascia  must  be  divided. 


Genito- crural  nerve 

Psoas  muscle 

\  asa  circumflexa  posterlora  ilii 

Lateral  cutaneous  femoral  nerve 


Promontory 
Conmion  iliac  artery 


Common  iliac  vein 
Internal  spermatic  vessels 
Internal  iliac  muscle 
Hypogastric  vein 
Hypogastric  artery 
External  iliac  artery 
'-  External  iliac  vein 


Fig.  07. 


176  OPEEATIVE    SURGEKY. 

The  Thigh  (Figs.  68,  69,  TO,  71). 

148.  Femoral  Artery. — It  descends  vertically  in  a  line  from 
the  middle  of  Poupart's  ligament  to  the  centre  of  the  popliteal 
space,  passing  backward  to  the  inner  surface  of  the  bone  at  the 
limit  of  the  middle  and  lower  thirds.  The  direction  of  the  inci- 
sions for  its  ligation  on  the  anterior  and  lateral  surfaces  can  be 
determined  by  a  line  from  the  middle  of  Poupart's  ligament  to 
the  internal  condyle  of  the  femur  (linea  inguino-condylica). 
On  the  lower  third  of  the  thigh  the  artery  lies  on  the  dorsal 
surface. 

Femoral  Artery  at  its  Entrance  into  the  Popliteal  Space 
(Figs.  78  and  79). — Incision  behind  the  cord-like  projecting  ten- 
don of  the  adductor  magnus  which  ends  at  the  internal  con- 
dyle of  the  femur.  Posteriorly  are  the  belly  of  the  sartorius, 
the  tendon  of  the  gracilis,  and  the  semi-tendinosus  (under  the 
latter  the  semi-membranosus).  In  the  subcutaneous  tissue  we 
find  the  great  saphena  vein.  After  dividing  the  fascia  the 
sartorius  muscle  presents;  between  it  and  the  tendon  of  the 
great  adductor  we  penetrate  into  the  depth  and  find  the  artery 
imbedded  in  fat  behind  the  tendon  at  the  bone ;  dorsad  toward 
the  skin  the  femoral  vein  and  the  tibialis  posticus  nerve.  After 
the  sartorius  muscle  is  drawn-  backward  we  expose  beneath  it 
the  internal  saphenus  nerve  with  a  branch  of  the  arteria  artic- 
ularis  genu  suprema. 

Above  the  Adductor  Fissure  (Figs.  68  and  69). — Longitudinal 
incision  at  the  limit  of  the  inferior  and  middle  thirds  of  the 
femur,  measured  from  the  anterior  superior  spine,  at  the  point 
where  the  finger  can  be  pressed  against  the  bone  between  the 
adductors  and  extensors  (quadriceps).  Incision  through  the 
skin,  preserving  the  great  saphena  vein,  division  of  the  fascia, 
when  the  sartorius  muscle,  characterized  by  its  longitudinal 
fibres,  is  drawn  inward  and  backward.  We  penetrate  at  the 
inner  surface  of  the  fascia  of  the  vastus  internus,  whose  fibres. 


LOWER   EXTREMITY.  177 

run  obliquely  forward.  This  fascia  is  severed  at  the  anterior 
margin  of  the  glistening  white  tendon  of  the  great  adductor. 
The  artery  is  rather  close  to  the  bone.  Postero-internally  is  the 
vein,  above  the  vascular  sheath  of  the  internal  saphenus  nerve. 
Care  is  needed  not  to  go  too  far  backward,  i.e.,  behind  the  ad- 
ductor tendon . 

In  the  Ujjj^er  Third  (Figs.  GS  and  69).— Skin  and  fascia  lata 
are  divided  in  the  inguino-condylic  line.  The  sartorius  is  drawn 
outward.  Under  this  muscle  lies  the  vascular  sheath  with  the 
branches  of  the  crural  nerve,  the  thickest  of  which  is  the 
saphenus,  laterally  from  the  artery.  The  femoral  vein  is  postero- 
internally.  Above  the  fascia,  in  a  median  direction  from  the 
incision,  is  the  great  saphena  vein. 

Common  Femoral  Artery  (Figs.  YO  and  Yl).— Transverse  in- 
cision below  the  palpable  Poupart's  ligament,  parallel  to  its 
middle  third.  The  superficial  epigastric  artery  in  the  subcuta- 
neous tissue  is  ligated.  The  superficial  layer  of  the  fascia  lata 
is  severed  under  Poupart's  ligament  which  is  distinctly  palpa- 
ble. The  artery  with  two  branches  (inferior  epigastric  inward 
and  circumflexa  ihi  outward)  appears  under  the  middle  of 
Poupart's  ligament,  resting  on  the  pubic  bone  and  distinctly 
palpable.  On  the  vascular  sheath  is  the  genito-crural  nerve ; 
inward  from  the  artery  the  femoral  vein,  outward  the  fascia  of 
the  ilio-psoas  muscle  under  which  the  trunk  of  the  crural  nerve 
descends  at  the  inner  margin  of  the  muscle. 

Branches   of  the  Femoral  Artery. 

14:9.  Superficial  Artery  of  the  Knee  Joint  (Figs.  68  and  69). 
—Incision  in  a  line  upward  from  the  internal  condyle  of  the 
femur.  The  skin  and  tense  fascia  are  divided.  The  sartorius 
muscle  is  drawn  backward.  Underneath,  imbedded  in  fat,  the 
internal  saphenus  nerve  becomes  visible,  accompanied  by  the 
superficial  branch  of  the  artery.  To  reach  the  deeper  main 
branch  we  proceed  toward  the  bone  above  the  prominent  glisten- 

12 


178 


OPERATIVE    SURGERY. 


Internal  iliac  muscle 

Poupart's  ligament 
Psoas  muscle 


Fig.  69. 


Fascia  of  external  abdominal 
/       oblique  muscle 
External  iliac  artery 
Superficial  epigastric  artery 
External  iliac  vein 

Internal  oblique  and  transverse  muscle 
Inferior  epigastric  artery 

,y : J  Superfieial  epi-      internal  cir-  J 

^/y        1  o.«=tr,^  «.t«..,.        cumflex  and  <- 
obturator  art.  S 


Point  midway  between 
symphysis  and  ant. 
^     sup.  iliac  spine 

I  Incision  for  ex- 
ternal iliac 
artery 


%& 


j^        j  gastric  artery 
'  -  ::^Femoral  vein 


^"Internal  circumflex  artery 
Pectineus  muscle 


Fefnoral  artery- 
Femoral  vein 
Adductor  longus  muscle 
Sartorius  muscle 

Internal  saphenus  nerve 


Sartorius  muscle 


-Femoral  artery- 


Femoral  vein 

Internal  saphenus  nerve 

Vastus  internus  muscle 

Tendon  of  adductor  magnus  muscle 


^ 


Superficial  artery  of  the  knee  joint- 
Tendon  of  adductor  magnus  muscle 
Vastus  internus  muscle 

Internal  condyle  of  the  femui 


mm 


Vii^ 


Fig. 


Figs.  68  and  69. — External  Iliac  Artery  and  Femoral  Artery  with  its  Branches. 


40WER   EXTREMITY, 


i7y 


Sartorius  muscle 


Ilio-psoas  muscle 
l'(  upait  s  ligament 
C  rural  nerve 


Point  midway  between 
symphysis  and  ant. 
sup.  iliac  Rpiue 


Circumflexa  ilii 


Lateral  cutaneous  feiuoral  nerve 


Common  femoral  artery. 


fienito-crural  nerve 
(    mmon  femoral  vein 
Pectmeus  muscle 

Superficial  epigastric  artery 

■^Crural  nerve 
_Sartorius  muscle 
Deep  femoral  artery 
Ciicmnflexa  externa  artery 
Femoral  artery 
Femoral  vein 

Deep  femoral  arterj 


Sartorius  muscle 
Adductor  longus  muscle 


Internal  condyle 


Fig.  71. 


Fig.  70. 


Figs.  70  and  71.— Femoral  Artery  with  it.s  Branches  and  Lateral  Cutaneous  Femoral  Nerve. 


180  OPERATIVE   SURGERY, 

ing  tendon  of  the  great  adductor,  under  the  vastus  internus 
muscle.  As  the  artery  springs  from  the  femoral  in  front  of  the 
adductor  fissure,  it  can  be  ligated  there  in  the  same  way  as  the 
latter  artery, 

a.  Deep  Artery  at  its  Origin  and  External  Circumflex 
Femoral  Artery  (Figs.  YO  and  Tl). — Incision  1  cm.  laterally 
from  the  middle  of  Poupart's  ligament,  beginning  two  fingers' 
breadth  below  it,  and  extending  straight  downward  (the  centre 
of  the  incision  corresponds  to  the  level  of  the  base  of  the  great 
trochanter).  The  skin  and  the  tense  fascia  lata  are  divided. 
The  inner  margin  of  the  sartorius  is  exposed  and  the  muscle 
drawn  outward.  Underneath,  imbedded  in  the  fat,  are  the 
branches  of  the  crural  nerve.  These  are  drawn  laterally  down- 
ward. The  lateral  margin  of  the  femoral  artery  now  becomes 
visible ;  laterally  and  downward  it  gives  off  the  profunda  artery 
and  the  external  circumflex  which  sinks  transversely  under  the 
rectus  femoris  muscle.  The  point  of  origin  corresponds  to  the 
lower  circumference  of  the  belly  of  the  ilio-psoas. 

h.  The  terminal  branch  of  the  external  circumflex  artery  is 
found  upon  the  bone,  one  finger's  breadth  under  the  highest 
lateral  prominence  of  the  great  trochanter,  by  dividing  the  skin, 
the  thick  fascia  lata,  and  the  body  of  the  vastus  externus  mus- 
cle transversely. 

150.  Deep  Artery  at  the  Adductor  Longiis  (Figs,  1Q  and 
Yl). — The  incision  is  made  as  for  the  ligation  of  the  femoral, 
vertically  through  skin  and  fascia,  at  the  limit  of  the  upper  and 
middle  thirds  of  the  femur,  a  hand's  breadth  under  the  inguinal 
fold.  The  exposed  sartorius  is  drawn  laterally,  but  instead  of 
opening  the  deep  fascia  on  the  vessels  (vascular  sheath)  as  for' 
the  femoral,  we  divide  medially  from  it  the  fascia  of  the  long 
adductor  and  enter  the  depth  toward  the  bone  on  the  outer  side 
along  the  body  of  this  muscle,  behind  the  femoral  vein.  At 
the  posterior  margin  of  the  vastus  internus  and  at  the  lateral 
upper   margin    of   the   adductor   longus   we   strike  the    large 


LOWER   EXTREMITY.  ,  l^i 

artery,   its  chief   prolongation   passing   under   the   last-named 
muscle. 

151.  Internal  Circumflex  Artery  (Figs.  68  and  60). — The 
artery,  as  a  rule,  branches  from  the  common  femoral ;  in  other 
cases  from  the  profunda  femoris.  Incision  one  finger's  breadth 
inward  from  the  middle  of  Poupart's  ligament,  passing  verti- 
cally through  the  skin ;  on  the  fascia  lata  we  find  the  great 
saphena  vein  which  is  drawn  laterally.  The  fascia  is  severed 
so  as  to  freely  expose  the  body  of  the  pectineus  muscle. 

At  the  lateral  margin  of  this  muscle,  below  the  obturator 
externus,  the  artery  passes  directly  backward  on  the  inner  side 
of  the  femur,  sending  a  large  branch  in  a  median  direction. 

The  artery  is  dissected  from  the  adipose  tissue  at  the  inner 
margin  of  the  femoral  vein.  When  derived  from  the  j^rofunda 
artery  it  passes  under  the  vein ;  when  from  the  common  femoral, 
occasionally  over  it,  though  in  most  cases  likewise  under  the  vein. 

152.  Crural  Nerve  (Figs.  70  and  71). — It  is  exposed  at  the 
point  for  the  ligation  of  the  external  circumflex  artery  (which 
see)  or  that  of  the  common  femoral.  Transverse  incision  as  for 
ligating  the  latter,  along  and  below  the  middle  third  of 
Poupart's  ligament.  The  incision  is  continued  laterally  through 
the  sheath  of  the  ilio-psoas  muscle,  and  immediately  under  it, 
on  the  medial  side  of  the  muscle,  is  the  thick  nerve,  dividing 
into  several  branches. 

153.  The  internal  saplienus  nerve  (Figs.  78  and  79)  accom- 
panies the  femoral  artery  to  the  fissure  of  the  adductor  and  lies 
on  the  vascular  sheath,  at  first  outward,  then  forward.  For 
its  exposure  at  the  knee  see  below. 

Above  the  line  of  the  joint  (Figs.  78  and  79)  it  is  to  be  looked 
for  in  front  of  the  prominence  of  the  sartorius,  under  which  it 
passes  backward  and  downward.  It  lies  at  the  margin  of  the 
adductor  tendon.  Incision  the  same  as  for  the  ligation  of  the 
superficial  artery  of  the  knee-joint. 

15-1.  Lateral  Cutaneous  Femoral  Nerve  (Figs.  70  and  71). — 


182 


OPEKATIVE   SURGERY. 


Tuber  ischii 


Posterior  cutaneous  femoral  nei  ve 

Semi-tendinosus  muscle 

Semi-membranosus  mubcle 


Popliteal  ai  tery 

Medial  head  of  the  gastrocnemiub' 

Popliteal  vein 

',  Lateral  head  of  the  gastrocnemius 


j  Posterior  margin  of  the 
I       great  trochanter 


Sciatic  nerve 
Posterior  cutaneous 
femoral  nerve 


—Belly  of  the  semi-muscles 


Belly  of  the  biceps 
femoris  muscle 


Biceps  femoris  muscle 
bciatic  nerve 


Peroneal  nerve 

1  ibialis  posticus  nerve 
Tendon  of  the  biceps  muscle 
Peroneal  nerve  (trunk) 


(  Trunk  of  the  tibio-peroneal 

_  •<      and  saphena  minor  vein 

/     vs^ith  suralis  medius  nerve 


Fig.  72. 


LOWER   EXTREMITY. 


183 


Tuber  ischi 


Popliteal  artery 
Suralis  raedius  nerve 


Saphena  minor  vein 
Medial  head  of  the  gastrocnemius  mus'le 


Glutseus  maximas  miis. 

Biceps  muscle 

Sciatic  nerve 
(  Posterior  cutaneous 
(       femoral  nerve 


Sciatic  nerve 


Peroneal  nerve 
Biceps  tendon 
External  sural  nerve 
Lateral  gastrocnemius  muscle 

Peroneal  nerve 

Trunk  of  the  tibio-peroneal 

Tibio-peroneal  vein 

Tibialis  posticus  nerve 
Soleus  muscle 

Lateral  head  of  the  gastrocne- 
mius muscle 


Fig.  73. 


184  OPERATIVE   SURGERY. 

Incision  one  finger's  breadth  below  the  anterior  superior  iliac 
spine  parallel  to  Poupart's  ligament,  through  skin  and  fascia. 
The  nerve  is  under  the  latter,  2  cm.  below  the  sj)ine,  passing 
obliquely  latero-inferiorly  over  the  external  margin  of  the  at- 
tachment of  the  sartorius. 

The  Thigh — Dorsal  Surface. 

155.  Sciatic  Nerve  (Figs.  72  and  Y3).  In  the  Lower  Half 
of  the  Thigh. — Incision  on  the  dorsal  surface  of  the  thigh,  mid- 
way between  the  bellies  of  the  semi-muscles  and  the  biceps 
femoris.  After  dividing  the  skin  the  thick  cutaneus  posticus 
nerve  appears  on  the  fascia.  The  muscles  are  to  be  separated, 
without  cutting,  and  deeply  between  them  on  the  dorsal  surface 
of  the  bone  lies  the  sciatic  nerve,  often  divided  into  its  two 
main  trunks.  In  the  upper  part  the  above-mentioned  depres- 
sion is  limited  on  the  medial  side  by  the  body  of  the  semi- 
tendinosus;  below,  where  the  muscle  becomes  tendinous,  the 
semi-membranosus  takes  its  place. 

At  the  Upper  End  of  the  Thigh  (Figs.  ^2  and  T3.) — Incision 
downward  from  the  gluteal  fold,  beginning  at  the  centre  of  a 
line  from  the  tuber  ischii  to  the  posterior  margin  of  the  great 
trochanter.  The  skin  and  fascia  are  divided.  The  lower  mar- 
gin of  the  glutseus  maximus  is  laid  bare  and  drawn  up.  The 
cutaneus  femoris  posticus  nerve  becomes  visible.  In  the  depth, 
at  the  outer  margin  of  the  biceps  muscle  which  is  drawn  in- 
ward, is  the  thick  nerve  trunk.  At  the  same  point,  but  deeper 
and  more  medially,  the  terminal  branch  of  the  inferior  gluteal 
artery  can  be  ligated  on  the  quadratus  femoris  muscle. 

At  its  Exit  from  the  Pelvis. — See  Ligation  of  the  sciatic 
artery,  page  168. 

Region  of  the  Knee  Joint. 

156.  Popliteal  Artery  (Figs.  ^72  and  Y3.) — Incision  in  the 
median  line  on  the  posterior  surface  of  the  knee  in  the  line  of 
the  joint.     In  the  lowest  part  of  the  incision  the  saphena  minor 


LOWER   EXTREMITY.  185 

vein  and  the  suralis  medius  nerve  (communicans  tibialis)  must 
be  spared  above  the  fascia.  We  penetrate  on  the  medial  side 
of  the  saphena  vein  through  the  fat  between  the  two  heads  of 
the  gastrocnemius ;  the  posterior  tibial  nerve  appears  first  and  is 
drawn  outward.  Then  the  vein  becomes  visible,  being  closely- 
united  to  the  underlying  artery  by  a  firm  sheath.  The  artery 
rests  in  the  upper  portion  on  the  fat  of  the  dorsal  surface  of  the 
femur;  in  the  lower  portion,  on  the  popliteal  muscle. 

157.  Peroneal  Nerve  (Figs.  Y2  and  73). — It  is  distinctly 
palpable  and  even  visible  behind  the  condyle  of  the  fibula  and 
still  better  on  the  posterior  surface  of  the  external  condyle  of 
the  femur. 

159.  Beside  it  can  be  felt  the  communicating  peroneal  nerve, 
especially  higher  up,  behind  the  external  condyle  of  the  femur. 
Incision  along  the  posterior  margin  of  the  biceps  tendon  from 
the  condyle  of  the  fibula  upward.  The  peroneal  nerve  lies 
directly  under  the  fascia  at  the  lateral  margin  of  the  gastroc- 
nemius, and  below  the  condyle  of  the  fibula  it  passes  into  the 
peroneus  longus  muscle,  having  given  off,  a  fev/  centimetres 
above,  the  lateral  sural  nerve  (communicans  peroneus). 

The  Leg — Anterior  Surface.  . 

160.  Tibialis  Antica  Artery  and  Peroneal  Nerves  (Figs.  7-4 
and  75). — The  course  of  the  tibialis  antica  artery  is  marked  by 
a  line  from  the  anterior  projection  of  the  external  condyle  of 
the  tibia  {i.e.,  a  point  midway  between  the  spine  of  the  tibia  and 
the  capitulum  fibulse)  to  the  centre  between  the  two  malleoli 
and  thence  to  the  first  intermetatarsal  interspace. 

In  the  Loiver  Third. — Incision  at  the  outer  margin  of  the 
tendon  of  the  tibialis  anticus  (the  first  thick  tendon  projecting 
laterally  from  the  sharp  anterior  edge  of  the  tibia),  passing  be- 
tween this  and  the  tendon  of  the  extensor  hallucis  longus.  The 
skin  and  the  very  thick  fascia  are  divided,  and  the  last-named 


186  OPERATIVE   SURGERY. 

tendon  is  freely  exposed  and  drawn  outward.  We  penetrate, 
without  cutting,  with  the  fingers  toward  the  outer  surface  of 
the  tibia.  Laterally  from  the  body  of  the  tibialis  anticus  muscle 
the  deep  peroneal  nerve  appears  first  and  beneath  it  the  artery. 

In  the  Middle  Third. — Incision  3  cm.  outward  from  the  edge 
of  the  tibia,  in  the  palpable  and  often  visible  depression  at  the 
lateral  margin  of  the  tibialis  anticus  muscle.  The  skin  is  di- 
vided and  then  the  fascia  along  a  white  line  in  the  latter  which 
indicates  the  above-named  depression  (a  second  white  line,  more 
laterally,  marks  the  interspace  between  the  extensor  hallucis 
longus  and  the  extensor  digitorum  communis  longus).  We 
penetrate  with  the  fingers  into  the  interosseal  space  upon  which 
the  artery  lies  with  the  def^p  peroneal  nerve  (to  the  outside), 
under  the  body  of  the  tibialis  anticus  muscle,  between  it  and 
the  extensor  hallucis  longus. 

At  the  Upper  End. — Downward  incision  from  the  centre  be- 
tween the  spine  of  the  tibia  and  the  capitulum  fibulae,  begin- 
ning a  thumb's  breadth  below  the  tuberosity  of  the  external 
condyle  of  the  tibia.  On  the  latter,  after  dividing  skin  and 
fascia,  the  attachment  of  the  tibialis  anticus  presents  as  a  later- 
ally tendinous  margin  which  marks  the  depression  toward  the 
extensor  digitorum  communis.  We  penetrate  with  the  fingers 
between  the  above-named  muscles  as  far  as  the  interosseal  liga- 
ment, at  whose  upper  end  the  artery  perforates  the  ligament 
from  behind,  about  one  finger's  breadth  below  the  head  of  the 
fibula.  The  deep  peroneal  nerve  comes  forward  a  little  farther 
down,  from  the  lateral  side  under  the  extensor  digitorum  com- 
munis muscle  against  which  it  rests.  The  nerve  gives  off  the 
branches  to  the  tibialis  anticus  muscle  quite  high  up. 

161.  Deep  Peroneal  Nerve  near  its  Origiyi  (Figs.  ^6  and 
Y7). — Incision  a  finger's  breadth  in  front  of  the  capitulum 
fibulae,  extending  downward  from  the  most  lateral  point  of  the 
external  condyle  of  the  tibia,  through  skin  and  fascia.  We 
penetrate  between  the  extensor  digitorum  longus  and  peroneus 


'iM  y  (  External  condyle  of 

vfW|ViV         "(     the  tibia 


Tibialis  anticus  muscl<^ 

Extensor  dipitonim  communis  | 

muscle  ) 

Tibialis  antica  artery 

Deep  peroneal  nerve 


^^^  ,  Belly  of  extensor  digitorum 

1    "^^/l^/ ^''  '/17k   '     loDgus  muscle 

'       '  Bellv  of  tibialis  anticus 
muscle 


Extensor  hallucis  longus  muscle 

Tibialis  antica  artery 

Deep  peroneal  nerve 
Tibialis  anticus  muscle 


Prominence  of  the  tendon  of 
the  tibialis  anticus  muscle 


Tibialis  anticus  muscl':  — 
Deep  peroneal  nerve 
Tibialis  antica  artery 

Extensor  hallucis  longus  muscle 


Point  midway  between  the  malleoli 

Extensor  hallucis  longus  muscle 

Ligameutum  cruciatum 

Superficial  peroneal  nerve 

Deep  peroneal  nerve 

Dorsalis  pedis  artery 

Deep  peroneal  nerve 

Dorsalis  pedis  artery ■ 

Tendon  of  ext.  hall,  longus  muscle- 
Superficial  peroneal  nerve' 
Extensor  hallucis  brevis  muscle 

Tendon  of  ext.  hall,  longus  muscle W^^ViT — 

Extensor  hallucis  brevis  muscle  • '-^•^  '^'~ 

Interosseus  muscle 
Superficial  peronealjien« 
Dorsahs  pedis  artery 

Deep  peroneal  nerve 
First  intermetatarsal  interspace 


Fig.  r-4. 


Figs.  74  and  75.— Tibialis  Antica  Artery;  Deep  Peroneal  Xerve. 


188  OPERATIVE   SURGERY. 

longus  muscles.  In  the  depth,  almost  transversely  in  front  of 
the  head  of  the  fibula,  the  nerve  passes  medially  in  the  above- 
named  furrow  under  the  extensor  longus  muscle,  while  the 
superficial  peroneal  nerve  passes  downward  below  in  the  same 
furrow. 

In  its  further  course  the  deep  peroneal  nerve  accompanies 
the  tibialis  antica  antery  for  its  entire  length  and  can  be  ex- 
posed by  the  same  incision.  It  lies  on  its  lateral  side,  except 
far  down  where  it  is  on  the  anterior  and  inner  side. 

162.  Superficial  Peroneal  Nerve  (Figs.  76  and  7Y).  In  the 
Upper  Third. — See  Exposure  of  the  deep  peroneal  nerve  under 
the  head  of  the  fibula. 

At  the  Middle  of  the  Leg. — Incision  at  the  anterior  surface 
of  the  belly  of  the  peroneal  muscles ;  division  of  skin  and  fascia. 
We  penetrate  between  the  muscles  named  (longus  above,  brevis 
below)  and  the  extensor  digitorum  longus.  The  peroneal  nerve 
is  drawn  laterally.  The  nerve  lies  deep  in  the  furrow,  becoming 
more  superficial  farther  down. 

At  the  Limit  of  the  Middle  and  Loiver  Thirds. — Incision 
midway  between  the  anterior  edge  of  the  tibia  and  the  posterior 
edge  of  the  fibula.  At  this  point  the  nerve  can  occasionally  be 
felt  through  the  skin. 

The  Leg — Dorsal  Surface. 

163.  Tibialis  Postica  Artery  and  Tibialis  Posticus  Nerve 
(Figs.  7S  and  79). — The  direction  of  the  incisions  for  ligation 
is  on  the  medial  surface  of  the  leg,  from  the  lower  margin  of 
the  internal  condyle  of  the  tibia  to  the  centre  between  the  in- 
ternal malleolus  and  the  Achilles  tendon. 

Behind  the  Internal  Malleolus. — Incision  midway  between  the 
Achilles  tendon  and  the  posterior  edge  of  the  tibia,  through  the 
skin  and  fascia  which  contain  stout  transverse  fibres  (ligamentum 
laciniatum)  and  under  which  the  arterv  lies  toward  the  malleo- 


LOWER   EXTREMITY. 


189 


Belly  of  peronei  muscles 
'  Belly  of  extensor  dip:i- 
/  torum  longus  muscle 


I  Point  midway  between 
■<  external  malleolus 
f     and  Achilles  tendon 


Fig.  77.  Fig.  76. 

Figs.  7C  and  77. — Peroneal  Nerve,  External  Saplienus  Nerve,  Sapliena  Minor  Vein. 


190  OPERATIVE   SURGERY. 

lus,  immediately  behind  the  flexor  tendons  (posteriorly  flexor 
hallucis  longus,  then  flexor  digitorum  communis,  anteriorly 
tibialis  posticus) .  The  very  thick  tibialis  posticus  nerve  lies 
dorsad.  Care  should  be  taken  not  to  penetrate  into  the  adipose 
tissue  situated  in  front  of  the  Achilles  tendon. 

In  the  Loiver  Third. — Downward  incision  from  the  upper 
angle  of  the  visible  and  palpable  furrow  between  the  deep 
flexors  (next  to  flexor  digitorum  longus)  and  the  anterior  margin 
of  the  soleus. 

The  skin  and  fascia  are  divided,  preserving  the  great  saphena 
vein  and  the  internal  saphenus  nerve  situated  behind  it.  After 
the  fascia  of  the  soleus  is  divided,  the  latter  is  drawn  backward. 
The  artery  lies  at  the  depth  of  1  to  2.5  cm.  on  the  posterior 
surface  of  the  flexor  digitorum  longus  which  adjoins  the  tibia, 
under  the  thin  fascia  of  this  muscle,  and  on  its  lateral  side  is 
the  tibialis  posticus  nerve. 

Above  the  Middle  and  in  the  Upper  Third. — Incision  at  a 
distance  of  1  cm.  from  the  inner  edge  of  the  tibia.  The  great 
saphenus  nerve  which  comes  within  the  line  of  the  incision,  and 
the  great  saphena  vein  in  front  of  it,  must  be  preserved.  After 
severing  the  fascia  the  attachment  of  the  soleus  to  the  tibia  is 
divided  until  we  come  to  the  obliquely  striated  tense  deep  fascia 
(the  inner  belly  of  the  gastrocnemius  is  merely  drawn  laterally 
downward) .  We  open  the  deep  fascia  which  is  attached  to  the 
dorsal  surface  of  the  tibia,  so  that  the  body  of  the  flexor  digi- 
torum longus  is  exposed.  We  penetrate  deeply  with  the  finger, 
laterally  between  this  muscle  and  the  deep  fascia,  and  find  the 
artery  3  cm.  from  the  edge  of  the  tibia,  resting  upon  the  tibialis 
posticus  muscle.  Laterally  from  it  is  the  thick  tibialis  posti- 
cus nerve.  We  must  particularly  avoid  penetrating  between 
the  tibia  and  the  flexor  longus  muscle,  or  between  the  soleus 
and  gastrocnemius,  or  above  the  deep  fascia. 

161.  Tihio- Peroneal  Trunk  (Figs.  72  and  73). — Incision  in 
the  median  line  under  the  popliteal  space,  downward  from  the 


LOWER   EXTREMITY, 


191 


Sartorius  muscle 
Popliteal  artery 

Tendon  of  the  great 
Internal    [adductor 
saphenus  n. 
Popliteal  artery  and 
superficial  arterj 
of  the  knee-joint 


Int'l  condyle  of  the  tibia  A 
Int'l  saphenus  nerve  & 
saphena  major  vein 


Plexor  digitorum  com-  (    h 

munis  longus  muscle   f 

.   Edge  of  the  tibia 

libialis  postica  artery 


Flexor  digitorum  com-  ( 
munis  longus  muscle    f       ,,. 

Tibialis  postica  artery  -    "■ 


Ligamentum  lajiniatum 


Fig.  79. 
Figs.  78  and  79.— Tibialis  Postica  Ai-tery, 


Inner  edge  of  the  tibia 


-Tibialis  posticus  nerve 
■Deep  fascia 


.    Belly  of 

flexor 
digitorum 
com.  Ion. 
Saphena  major  vein  and  in-  / 
ternal  saphenus  nerve 

Tibialis  postica  artery 
Tibialis  posticus  nerve 

b  at  Point  midway  between  inter- 
nal malleolus  and 
Achilles  tendon  j(^^^ 

Infl and exfl  plantar n.  /      /^    '.. 
and  ai-t.  at  their  origin   i"  'A  •'>/''  ■ 


Fig.  78. 

TibiaUs  Posticus  Nerve,  lutenial  Saphenus 
Major  Vein. 


Nerve,  Saphena 


192  OPERATIVE   SURGERY. 

horizontal  level  of  the  head  of  the  fibula.  We  divide  the  fascia, 
hut  preserve  the  minor  saphena  vein  and  beside  it  the  commu- 
nicans  tibialis  nerve  (suralis  medius).  These  structures  are 
drawn  inward.  They  mark  the  contact  of  the  two  heads  of  the 
gastrocnemius  between  which  we  penetrate.  The  large  vascular 
and  nerve  branches  passing  to  the  two  heads  of  the  gastrocne- 
meus  are  drawn  aside.  Under  the  lateral  head  we  strike  the 
margin  of  the  attachment  of  the  soleus  which  descends  inward 
from  above  and  without,  and  the  thin  tendon  of  the  plantaris 
longus  which  passes  inward  and  downward.  At  the  upper 
margin  of  the  soleus  the  trunk  of  the  tibio-peroneal  begins, 
after  giving  off  the  tibialis  antica  artery.  Hence  the  margin 
of  the  soleus  must  be  drawn,  downward  or  nicked  so  as  to  get 
under  that  large  branch.  As  in  the  case  of  the  popliteal  artery 
the  tibialis  posticus  nerve  and  the  vein  are  drawn  outward  in 
order  to  reach  the  artery.  The  popliteal  artery  descends  on  the 
popliteal  muscle,  at  whose  inferior  margin  it  gives  off  the  tibialis 
antica  artery  forward  through  the  interosseal  ligament,  about 
6  cm.  below  the  line  of  the  knee  joint. 

The  Leg — External  Surface. 

165,  Peroneal  Artery  (Figs.  80  and  81).  The  direction  of 
its  course  is  in  a  straight  continuation  of  the  popliteal  artery 
along  the  medial  posterior  surface  of  the  fibula.  The  posterior 
surface  of  the  fibula  can  be  felt  through  the  entire  length  of 
the  leg.  The  incisions  are  made  in  a  line  passing  from  the 
posterior  circumference  of  the  head  of  the  fibula  to  a  point  be- 
tween the  internal  malleolus  and  the  Achilles  tendon.  The 
artery  arises  in  the  upper  third  of  the  leg  from  the  tibio-peroneal 
trunk. 

Above  the  Middle. — Incision  upon  the  posterior  fibular  sur- 
face behind  the  eminence  of  the  peroneal  muscles.  The  com- 
municating peroneal  nerve  comes  in  view.     The  fascia  lata  is 


LOWER  EXTREMITY. 


193 


Fig.  81. 


Fig.  80. 


13 


194  OPERATIVE    SURGERY, 

divided  behind  the  peroneal  muscles.  The  attachment  of  the 
soleus  is  separated  from  the  fibula  until  the  deep  fascia  presents 
which  covers  the  flexor  hallucis  longus  muscle  on  the  dorsal 
surface  of  the  fibula.  After  this  fascia  is  severed,  we  penetrate 
into  the  depth  between  it  and  the  muscle  and  at  the  medial 
margin  of  the  latter  find  the  artery  before  it  enters  the  muscle 
or  between  the  fascia  and  the  posterior  surface  of  the  muscle. 

Below  the  Middle. — Incision  at  the  posterior  surface  of  the 
fibula  as  above.  After  the  fascia  is  divided,  the  soleus  muscle 
is  drawn  medially.  The  artery  lies  superficially  under  the  deep 
fascia  which  covers  the  flexor  hallucis.  The  tibialis  posticus 
nerve  lies  in  a  median  and  posterior  direction  from  it. 

166.  Internal  Saphenus  Nerve  (Fig.  78).  a.  At  the  Knee. — 
Incision  in  the  line  of  the  joint  at  the  posterior  inferior  circum- 
ference of  the  internal  condyle  of  the  tibia,  behind  the  tendon 
of  the  sartorius.  The  nerve  is  in  the  furrow  between  the  sarto- 
rius  in  front  and  the  stout  tendon  of  the  gracilis  behind.  The 
saphena  major  vein  lies  on  the  fascia. 

h.  On  the  leg  the  nerve  is  found  throughout  its  entire  length 
along  the  inner  edge  of  the  tibia  beside  the  saphena  major  vein, 
in  the  line  of  the  incisions  made  for  the  ligation  of  the  tibialis 
postica  artery. 

c.  At  the  ankle  joint  the  nerve  is  palpable  beside  the  saphena 
major  vein  at  the  anterior  circumference  of  the  internal  mal- 
leolus. 

167.  Suralis  Externus  Nerve  {Communicans  Peronei).  At 
the  upper  end  (Figs.  72  and  73)  the  nerve  is  exposed  by  the 
same  incision  as  the  trunk  of  the  peroneal  nerve,  close  to  the 
biceps  tendon,  directly  under  the  fascia. 

At  the  Loiver  End  (Figs.  76  and  77). — Incision  midway  be- 
tween the  external  malleolus  and  the  Achilles  tendon.  Here 
the  nerve  is  subfascial,  having  united  with  the  communicans 
tibialis  to  form  the  external  saphenus  nerve.  The  saphena 
minor  vein  lies  beside  it. 


LOWER   EXTREMITY.  195 

168.  Tibialis  Posticus  Nerve  (Figs.  Y8  and  79).— To  be  ex- 
posed in  the  entire  length  along  the  tibialis  postica  ai'tery ;  being 
laterally  from  it  above,  posteriorly  below,  and  inferiorly  in  the 
sole  of  the  foot  {i.e.,  nearer  the  skin). 

169.  Suralis  Medius  Nerve  {Communicans  Tibialis;  Figs. 
72  and  73). — See  Ligation  of  the  popliteal  and  tibio-peroneal 
arteries.  In  the  upper  two-thirds  of  the  leg  the  nerve  descends 
vertically  on  the  fascia  with  the  saphena  minor  vein,  in  the 
middle  of  the  calf. 

The  Foot. 

Plantar  Arteries  and  Nerves. — In  the  median  line  of  the 
sole  of  the  foot  the  deeper  structures  are  covered  by  the  body  of 
the  flexor  brevis  muscle.  Analogous  to  the  palm  of  the  hand, 
therefore,  we  enter  alongside  of  this  median  bundle  and  the  two 
lateral  muscular  eminences.  The  latter  consist  superficially  of 
the  abductors  of  the  great  and  little  toe. 

170.  The  Plantar  Arch  at  the  Intermetatarsal  Interspace 
(Fig.  82). — Incision  in  the  depression  laterally  from  the  ball 
of  the  great  toe,  in  the  direction  of  a  line  from  the  second 
toe  to  the  tuberosity  of  the  os  calcis,  backward  through  the 
skin,  the  abundant  adipose  tissue,  and  the  tense  plantar  apo- 
neurosis. The  internal  plantar  nerve  is  exposed  with  its  thick 
branches.  It  is  to  be  drawn  toward  the  inner  margin  of  the 
foot.  The  tendon  of  the  flexor  digitorum  brevis  to  the  second 
toe,  and  at  its  medial  margin  and  more  deeply  that  of  the  flexor 
digitorum  longus  with  the  first  lumbrical,  are  exposed  and 
drawn  laterally.  Under  these  is  the  thick  adductor  hallucis 
muscle.  Rather  deeply  under  the  latter  muscle  we  strike  the 
point  where  the  artery  passes  through  the  first  metatarsal  inter- 
space. 

171.  Internal  Plantar  Arterij  and  Nerve  (Figs.  82  and  83). 
— Incision  in  tlie  direction  from  the  tip  of  the  tuberosity  of  the 
OS  calcis  to  the  first  toe  (Fig.  83),  from  the  anterior  circumfer- 


196  .  OPERATIVE   SURGERY. 

ence  of  the  eminence  of  the  heel  forward  through  the  skin,  the 
abundant  fat,  and  the  firm  plantar  aponeurosis  with  its  longi- 
tudinal fibres. 

The  body  of  the  abductor  hallucis  is  exposed.  The  flexor 
brevis  digitorum  lies  laterally.     The  vessel  and 

172.  The  internal  plantar  nerve  are  situated  under  this 
muscle.  The  artery  is  very  small,  the  nerve  thick  and  covered 
with  abundant  fat.  The  tendon  of  the  flexor  hallucis  longus 
lies  under  these  structures. 

173.  External  Plantar  Artery  and  Nerve  (Figs.  82  and  83). — 
Incision  in  the  course  of  a  line  from  the  tip  of  the  tuberosity  of 
the  OS  calcis  to  the  fourth  toe,  forward  from  the  eminence  of 
the  heel  through  the  skin,  the  abundant  fat,  and  the  thick 
plantar  aponeurosis.  The  body  of  the  flexor  brevis  digitorum 
is  exposed,  between  which  and  the  short  head  of  the  flexor 
longus  the  artery  and 

174.  The  external  plantar  nerve  appear  laterally,  the  former 
very  thick,  the  latter  narrow.  The  deeper  tendons  are  not 
exposed. 

175.  Plantar  Arteries  at  their  Origin  from  the  Tibialis 
Postica  Artery  (Figs.  78  and  82). — Incision  beginning  on  the 
medial  side  of  the  foot,  one  flnger's  breadth  under  the  palpable 
sustentaculum  tali,  extending  horizontally  backward.  Division 
of  the  skin  and  the  ligamentum  laciniatum,  under  which  the 
body  of  the  abductor  hallucis  is  exposed.  This  is  lifted  from 
the  inner  surface  of  the  os  calcis.  The  two  arteries  with  the 
plantar  nerve  rest  on  the  flexor  tendons. 

176.  Dorsalis  Pedis  Artery  (Figs.  74  and  75). — Course, 
from  a  point  midway  between  the  two  malleoli  to  the  first 
metatarsal  interspace. 

At  its  Entrance  into  the  Metatarsal  Interspace. — Incision 
between  the  bases  of  the  first  and  second  metatarsals.  The 
skin  and  fascia  are  divided,  sparing  a  branch  of  the  superficial 
peroneal  nerve  which  is  drawn  laterally,  as  is  also  the  saphena 


LOWER   EXTREMITY. 


197 


major  vein.  In  a  median  direction  appears  the  tendon  of  tlie 
extensor  hallucis  brevis,  and  still  farther  medially  the  thick 
tendon  of  the  extensor  hallucis  longiis.     Under  the  lateral  mar- 


Plantar  artery  at  its  origin 
\ 


External  plantar  aiterj^ 
Abductor  hallucis  i  i,2'j  i  Internal  plantarnerve 
I  B':F  Internal  plantar  artery 
Flexis  brevis  digitorum  *^-' 

Fig.  82.— Internal  Plantar  Artery  and  Nerve. 


Internal  plantar  artery  ^/_ 


Flexor  bievis  lisit-ii  im 


\\ 

Fat        1  External  plantar  aiteiy 


External  piauLai  ueive 
Fig.  83.— External  Plantar  Artery  and  Nerve. 

gin  of  the  former  the  deep  peroneal  nerve  emerges  and  under  it 
the  artery,  a  thick  interdigital  branch  of  which  passes  forward. 
Midway  on  the  Dorsum  of  the  Foot. — Incision  in  the  above- 
named  direction.  On  the  fascia  the  superficial  peroneal  nerve 
is  drawn  outward.     Under  the  fascia  we  expose  the  tendon  of 


198  OPERATIVE    SURGERY. 

the  extensor  hallucis  longus,  and  laterally  the  tendon  and  body 
of  the  extensor  hallucis  brevis  muscle.  The  latter  is  drawn 
laterally  downward,  and  the  artery  is  found  beneath;  the  deep 
peroneal  nerve,  which  is  rather  thick,  being  on  its  external  side. 
The  artery  rests  on  the  articular  ligaments. 

In  the  Line  of  the  Ankle  Joint. — The  skin  is  divided  mid- 
way between  the  two  malleoli.  The  superficial  peroneal  nerve 
appears  in  the  direction  of  the  incision  and  is  drawn  outward. 
We  open  the  fascia  with  the  ligamentum  cruciatum  above  the 
tendon  of  the  extensor  hallucis  longus;  this  muscle,  which  still 
contains  muscular  fibres,  is  drawn  in  a  median  direction.  Be- 
neath it  is  the  artery,  outward  and  forward  of  it  the  deep  pero- 
neal nerve. 


PART  III. 

EXCISIONS    (RESECTIONS). 
T.  General  Observations. 

Definite  types  of  operation  can  be  laid  down  for  the  excision 
of  the  bones  and  joints.  As  regards  the  soft  parts  it  is  not 
worth  while  to  separate  excisions  from  incisions,  unless  the 
pathological  side  of  the  subject,  especially  tumors,  is  to  be  con- 
sidered at  the  same  time.  By  excision  is  meant  the  removal  of 
a  portion  of  an  organ  or  member  from  the  continuity  of  an 
organ  or  part  of  the  body.  In  the  case  of  the  joints  it  is  cus- 
tomary to  employ  for  the  oj)eration  the  special  term  "resection." 
Eesections  form  the  greater  portion  of  this  part  of  the  book ;  as 
to  the  excision  of  bones  we  shall  restrict  ourselves  in  the  main 
to  the  total  removal  of  the  small  bones. 

As  regards  the  technique,  excisions  belong  to  the  simplest 
operations.  For  as  soon  as  the  part  in  question  is  once  laid 
bare,  the  task  is  to  enucleate  it  as  thoroughly  as  possible  from 
its  surroundings,  the  adjoining  soft  parts  being  immediately 
detached  from  the  bone  (when  such  is  the  one  to  be  resected) 
with  sharp  or  blunt  instruments.  The  resection  is  correct  in 
proportion  to  the  thoroughness  with  which  the  bone  is  laid  bare, 
i.e.,  in  inverse  proportion  to  the  number  of  soft  parts  adhering 
to  it.  This  simple  rule  is  largely  violated  by  beginners  in  the 
practice  of  resection. 

The  point  which  will  be  again  emphasized  under  amputations 
in  connection  with  Ollier's  subcapsular  and  subperiosteal  method, 
is  the  most  important  requirement  here  for  the  incisions  in  the 
depth.     In  recent  years  surgeons  have  even  gone  beyond  this 


200  OPERATIVE   SURGERY. 

subcapsulo-periosteal  method  of  resection  (Konig,  Bergmann, 
Eiedel,  Tiling)  and  have  recommended  instead  of  the  detach- 
ment of  the  ligaments,  particularly  the  lateral  ones,  the  chisel- 
ling away  of  the  bony  processes  (tubercles,  trochanters,  con- 
dyles, malleoli),  a  sort  of  osteoplastic  resection.  Oilier  made 
use  of  this  method  even  earlier  in  isolated  cases;  we  employ 
it  for  the  resection  of  the  shoulder  and  partly  of  the  elbow. 

The  only  difficult  and  important  portion  of  the  operation  is 
the  correct  location  of  the  first  incision.  This  must  answer  the 
requirement  of  giving  perfectly  free  access  to  the  depth.  This 
access  is  to  be  direct,  and  moreover  in  the  division  of  the  over- 
lying soft  parts  no  unnecessary  incidental  injury  should  be 
caused.  Therefore,  not  only  should  larger  vessels  and  nerves 
be  spared,  but  even  muscles  and  tendons  should  be  avoided,  and 
in  choosing  interstices  between  muscles  and  tendons — a  point 
upon  which  we  lay  particular  stress — only  those  should  be 
selected  which  correspond  to  the  borders  of  nerve  distribution. 
If  the  function  of  a  muscle  is  to  be  preserved,  its  motor  nerve 
must  remain  intact.  This  consideration  is  decisive  for  the 
method  of  resection. 

U.  Lower  Extremity. 

177.  Excision  of  the  Phalanges  of  the  Toes  and  the  Meta- 
tarsal Bones  (Fig.  84). — According  to  the  statements  made  in 
connection  with  incisions  on  the  toes  and  fingers,  it  is  evident 
that  only  lateral  incisions  closer  to  the  dorsum  are  admissible 
in  order  to  spare  nerves  and  tendons.  On  the  toes  and  their 
joints  it  is  more  conservative  as  regards  the  performance  of  the 
operation,  and  more  suitable  with  reference  to  the  cicatricial 
petraction,  to  make  two  smaller  lateral  incisions ;  for  the  meta- 
tarsal bones  a  dorsal  incision  along  the  extensor  tendons  and 
the  digital  branches  of  the  peroneal  nerves  is  sufficient.  The 
incision  must  extend  beyond  the  adjoining  joints  if  it  is  to 


LOWER   EXTREMITY. 


201 


afford  ample  room.  The  head  of  the  bone  is  always  first  laid 
bare  because  its  ligamental  connections  are  more  easily  detached 
than  those  of  the  base. 

178.  Metatarso-Tarsal  and  Anterior  Tarsal  Resection 
(Figs,  81  and  85). — This  is  a  very  important  operation  in  infec- 
tious diseases   (especially  tuberculosis)  of   the  anterior  tarsal 


Fig.  84. — Resection  of  the  Phalanges. 
Resection  of  the  Metatarsal  Bones, 


Fig.  85. — Anterior  Tarsal  Re- 
section (Usual  Arrange- 
ment of  the  Joint  Capsules). 


joints  because,  as  a  rule,  all  their  capsules  communicate  with  one 
another.  Closed  capsules  are  found  most  frequently  at  the  joint 
between  the  first  metatarsal  and  the  first  cuneiform,  at  the  ante- 
rior and  posterior  surface  "of  the  cuboid,  between  the  head  of  the 
talus  and  navicular  bone,  the  talus  and  calcaneus.  Tubercular 
ostitis  frequently  begins  in  the  base  of  the  metatarsal  bones,  and 
then  occasionally  a  resection  of  the  bases  of  the  metatarsal  bones 
and  the  articular  surfaces  of  the  adjoining  cuneiform  bones  and 


202  OPERATIVE    SURGERY. 

the  cuboid  may  suffice  (metatarso- tarsal  resection) .  If  the  joints 
are  involved,  the  simultaneous  removal  of  the  last-named  bones 
together  with  the  navicular  will  be  more  certain.  In  diffuse 
disease  the  articular  surfaces  of  the  talus  and  calcaneus  are  to 
be  likewise  removed. 

The  resection  is  made  from  two  dorsally  placed  lateral  inci- 
sions. The  medial  incision  extends  from  the  posterior  third  of 
the  first  metatarsal  to  the  inner  circumference  of  the  head  of 
the  talus  which  becomes  visible  when  the  foot  is  abducted.  At 
the  latter  point  the  incision  is  carried  through  the  skin  only, 
lest  the  ankle-joint  capsule  be  opened,  which  reaches  to  the  neck 
of  the  talus.  The  incision,  beginning  in  a  median  direction 
from  the  extensor  tendon  of  the  great  toe,  divides  the  attach- 
ments of  the  tibialis  anticus  to  the  first  metatarsal  and  the  first 
cuneiform  bone  and  frees  the  dorsal  surface  of  the  cuneiform 
and  navicular  bones.  Downward,  the  lower  surface  of  the 
latter  bone  is  freed  in  the  same  way ;  the  tendon  of  the  tibialis 
posticus  is  left  postero-inferiorly. 

The  lateral  incision,  passing  from  the  posterior  third  of  the 
fifth  metatarsal  to  the  upper  surface  of  the  body  of  the  calca- 
neus in  front  of  the  external  malleolus,  remains  lateral  from 
the  tendons,  by  separating  the  attachment  of  the  peroneus 
tertius  from  the  fifth  metatarsal  and  freeing  the  upper  surface 
of  the  metatarsal  bases  and  the  cuboid  bone.  In  order  to  ex- 
pose the  lower  surface  of  this  bone  the  tendon  of  the  peroneus 
brevis  must  be  detached  from  the  fifth  metatarsal  and  that  of 
the  peroneus  longus  lifted  from  the  groove  at  its  outer  and 
lower  surface  and  drawn  backward. 

Then  follows  the  removal  of  the  bases  of  the  metatarsal 
bones  and  the  articular  surface  of  the  talus  and  calcaneus. 

The  shortened  foot  continues  exceedingly  useful  both  as  re- 
gards support  and  locomotion. 

1Y9.  Intertarsal  Resection  (Fig.  86). — This  operation  is  rela- 
tively frequent  for  clubfoot.     The  incision  follows  the  cutaneous 


LOWER   EXTREMITY. 


203 


folds  transversely  over  the  line  of  the  joint  on  the  anterior 
outer  side ;  the  tendons  of  the  anterior  surface,  exteriorly  that 
of  the  peroneus  tertius,  being  drawn  in  a  median  direction ;  on 
the  outer  side  the  tendon  of  the  peroneus  longus  is  lifted  from 
the  groove  of  the  calcaneus  and  cuboid  bones  and  drawn  back- 
ward. The  extensor  digitorum  brevis  muscle  is  separated  at 
its  upper  margin  from  the  bone  and  drawn  forward  and  down- 
ward. The  joint  capsule  is  then  incised  in  Chopart's  line  and 
as  a  rule  the  entire  navicular  bone,  a  portion  of  the  cuboid,  the 


Fig.   86.  —  Jledio-tarsal  Eesection  (Wedge- 
shaped  Excision  ia  Clubfoot). 


Fig.  87.— Excision  of  tlie  Tains  (Outer  Side). 


calcaneus,  and  the  head  and  neck  of  the  talus  are  cut  through 
subcapsulo-periosteally  (in  children  with  the  chisel)  so  that  the 
foot  can  be  straightened  slightly  beyond  a  right  angle,  the 
supination  and  adduction  being  corrected.  Suture  without 
drainage,  immediate  closed  plaster  dressing  in  good  position. 

180.  Excision  of  the  Talus  (Fig.  ST). — While  it  appears  to 
be  unnecessary  to  give  definite  directions  for  the  excision  of  the 
small  tarsal  bones  which  is  occasionally  required,  an  exception 
must  be  made  of  the  talus  and  calcaneus,  whose  removal  is 
more  frequently  performed  for  tuberculosis,  injuries,  and  club- 
foot.    The  latter  two  indications  apply  especially  to  the  talus. 

As  a  rule  a  free  lone'itudinal  incision  on  the  anterior  outer 


204 


OPERATIVE   SURGERY. 


side  suffices,  such  as  the  one  given  by  Vogt  for  the  resection  of 
the  ankle  joint. 

Beginning  a  hand's  breath  above  the  ankle  joint  at  the 
anterior  surface  of  the  fibula,  it  passes  on  the  outer  side  of  the 
extensor  tendons  (peroneus  fortius),  leaving  the  branches  of  the 
superficial  peroneal  nerve  in  a  median  direction,  over  the  lateral 
margin  of  the  pulley  of  the  talus  which  is  readily  felt  in  adduc- 
tion, as  far  as  the  tuberosity  of  the  fifth  metatarsal ;  it  pene- 
trates into  the  ankle  joint  and  Chopart's  articulation,  exposing 
the  pulley  and  head  of  the  talus.     On  the  neck  of  the  talus  the 


Fig.  88.— Excision  of  the  Calcaneus. 


Fig.  89.  —  Frontal  Section 
of  the  Ankle  Joint,  after 
Henle. 


attachment  of  the  anterior  and  posterior  joint  capsules  is  freely 
separated  toward  both  sides  and  in  the  sinus  of  the  tarsus  lat- 
erally the  tense  interosseous  ligament  is  divided.  Along  the 
anterior  margin  of  the  tibia  and  fibula  the  joint  capsule  is  de- 
tached, and  laterally  at  the  anterior  and  posterior  end  of  the 
talus  pulley  the  ligamentum  talo-fibulare  anticum  and  posticum 
is  divided.  Externally  and  along  the  posterior  margin  of  the 
talus  the  capsular  connection  with  the  calcaneus  is  separated. 
In  a  forced  adduction  position  the  talus  can  now  be  lifted  far 
enough  to  permit  the  insertion  of  an  elevator  beneath  it  so  that 
the  attachments  of  the  ligaments  and  capsules  on  the  inner  side 
can  be  separated. 


LOWER   EXTREMITY. 


•^05 


181.  Excision  of  the  Calcaneus  (Figs.  S8  and  89). — Where 
the  soft  parts  are  flexible,  sufficient  room  is  furnished  by  a 
longitudinal  incision  on  the  medial  side  close  to  the  Achilles 
tendon  downward  to  the  lowest  posterior  end  of  the  tuber  cal- 
canei,  and  thence  transversely  across  to  the  outer  side  as  far 
as  the  tuberosity  of  the  fifth  metatarsal. 

At  the  posterior  root  of  the  tuber  the  Achilles  tendon  is  de- 
tached, the  joint  capsule  at  the  postero-external  circumference 
of  the  calcaneus  is  severed  together  with  the  calcaneo-fibular 
ligament ;  the  peroneal  tendons  in  the  tarsal  sinus  being  drawn 
up,  the  interosseus  ligament  is  divided,  and  the  joint  capsule  to 
the  cuboid  bone  infero-externally  detached  together  with  the 


Fig.  90. — Posterior  Tarsal  Rejection. 

firm  calcaneo-cuboid  ligament.  The  heel-cap  is  vigorously 
drawn  over  to  the  medial  side,  the  tendon  of  the  tibialis  jDosticus 
is  freed  below  at  the  sustentaculum  tali  and  lifted  up,  and 
finally  the  attachment  of  the  joint  capsule  to  the  talus,  with 
the  covering  deltoid  ligament  (ligamentum  calcaneo-tibiale)  and 
in  front  the  stout  ligamentum  tibio-calcaneo-naviculare,  is  sepa- 
rated.    The  bone  must  be  seized  with  strong  forceps. 

182.  Tola -Calcaneus  and  Posterior  Tarsal  Resection  (Fig, 
90). — The  resection  of  the  articulation  between  the  talus  and 
calcaneus  has  been  performed  by  Annandale,  by  means  of  two 
lateral  curved  incisions,  and  it  can  be  done  by  the  method  de- 
scribed for  the  excision  of  the  calcaneus  or  the  modified  method 
for  the  posterior  tarsal  resection. 

The  posterior  tarsal  resection,  which  is  associated  with  re- 


206  OPERATIVE   SURGERY. 

moval  of  the  talus  and  calcaneus  and  possibly  the  adjoining 
articular  surfaces,  furnishes  unexpectedly  good  results  with  the 
foot  in  normal  position,  the  leg  bones  descending  to  fill  the  de- 
fect (Kocher,  Kummer). 

The  procedure,  according  to  the  method  to  be  described,  is 
based  on  the  possibility  of  preserving  the  tendons  and  muscles 
moving  the  foot  (peronei,  tibialis  anticus  and  posticus). 

Incision  beginning  a  hand's  breadth  above  the  ankle  joint 
on  the  outer  side  beside  the  Achilles  tendon,  extending  down- 
ward behind  the  external  malleolus  and  the  peroneal  tendons  as 
far  as  the  tuberosity  of  the  fifth  metatarsal.  From  this  incision 
the  tendon  sheaths  of  the  peronei  are  opened,  these  tendons 
lifted  forward,  and  in  a  manner  analogous  to  that  described  for 
the  excision  of  the  talus  and  calcaneus  these  two  bones  are  ex- 
articulated  ;  then  the  articular  surfaces  of  the  leg  bones  and  of 
the  cuboid  and  navicular  are  ablated.  It  is  desirable  to  preserve 
a  small  projection  of  the  external  malleolus  for  the  purpose  of 
hooking  the  peroneal  tendons  behind  it. 

If  the  tuber  calcanei  can  be  preserved,  it  may  be  utilized  for 
osteoplastic  purposes  in  an  analogous  manner  to  that  of  Piro- 
goff  in  amputation  of  the  foot.  It  will  be  sufficient  to  illustrate 
this  case  by  the  lines  of  the  saw  in  the  adjoining  figure. 

183.  Resection  of  the  Foot  (Figs.  91  and  92). — The  resection 
in  the  talo-crural  joint  does  not  always  give  satisfactory  results, 
owing  to  the  complicated  structure  of  the  joint,  the  frequent 
involvement  of  the  directly  adjoining  bones,  and  of  the  neigh- 
boring talo-tarsal  articulation  with  its  bones,  especially  the 
calcaneus.  Hence  the  efforts  directed  to  the  continual  improve- 
ment of  the  technique.  Incisions  have  been  made  on  all  sides 
of  the  joint,  in  every  direction. 

Anterior  longitudinal  incisions  are  made  by  Vogt  (lateral), 
Konig  and  Riedel  (bilateral  with  chiselling  away  of  the  mal- 
leoli), Meinhardt  Schmidt  (conjoined  with  posterior);  anterior 
transverse  incisions  by  Hiiter,  formerly  by  Sabatier,  Heyfelder, 


LOWER  EXTREMITY. 


207 


Hancock ;  posterior  transverse  incision  by  Liebrecht,  conjoined 
with  posterior  longitudinal  incision  by  Wackley,  Textor ;  inferior 
"stirrup-heel"  incision  by  Busch,  Hahn,  Ssabanejew  (with  de- 
tachment of  the  tuber  calcanei) ;  lateral  incisions,  in  part  associ- 
ated with  transverse  incisions,  by  Moreau,  Langenbeck,  Oilier, 
Chauvel,  Girard. 

We  recommend  the  external  lateral  transverse  incision 
(Reverdin,  Kocher).  The  incision  (see  Fig.  91)  begins  at  the 
height  of  the  ankle  joint,  extending  from  the  outer  margin  of 
the  extensor  tendons,  or  the  still  fleshy  peroneus  tertius,  in  a 


Supei'flcial  peroneal  uerve  v 
Peroueus  tertius  muscle.  \ 

Extensor  communis  muscle, 


Fissure  of  the  joint 
Exfl  sapbeiius  nerve 
Tendons  of  the  pero- 
neal muscles 


i'lo..  './I. — Resection  of  the  booi. 


curve  over  the  tip  of  the  external  malleolus  as  far  as  the  Achilles 
tendon,  leaving  the  latter  intact.  Skin  and  fascia  are  divided ; 
in  front  the  superficial  peroneal  nerve  is  preserved  and  drawn 
aside  together  with  the  extensor  tendons ;  posteriorly  we  must 
preserve  the  external  g'aphenus  nerve,  lying  behind  the  peroneal 
tendons,  which  is  formed  by  the  union  of  the  communicans 
peroneus  and  tibialis  and  supplies  the  outer  side  of  the  foot,  also 
alongside  of  the  Achilles  tendon  cutaneous  branches  passing  to 
the  heel,  and  the  saphena  minor  vein.  Where  these  structures 
cannot  be  preserved  they  may  be  divided  without  causing  ma- 
terial injury. 

In  front  the  incision  now  extends  between  the  extensors  and 
the  fibula  into  the  joint,  and,  the  extensors  being  forcibly  ele- 


208 


OPERATIVE   SURGERY. 


vated,  separates  the  capsular  attachments  along  the  anterior 
margin  of  the  fibula  and  tibia  to  the  internal  malleolus  and 
from  the  pulley  of  the  talus  at  the  neck  of  this  bone  as  far 
medially  as  possible.  The  dorsal  artery  of  the  foot,  lying  on 
the  joint  capsule  with  the  deep  peroneal  nerve,  remains  intact. 

-  Patella 


Spine  of  the  tibia 


Talus  pulley 
Peroneal  tendon 


Peroneus  tertius  muscle 

■Tibial  joint  surface 
External  malleolus 


Capsule 


Fig.  92.— Resection  of  the  Foot. 


Close  around  the  external  malleolus  the  capsule  and  liga- 
ments are  detached  throughout,  the  latter  especially  also  from 
the  inner  surface  of  the  malleolus  where  they  knit  the  joint 
with  great  firmness.  At  the  tip  and  the  posterior  margin  of 
the  external  malleolus  the  separation  of  the  ligaments  is  associ- 
ated with  the  opening  of  the  sheath  of  the  peronei,  posteriorly 
upward  above  the  line  of  the  joint,  so  that  the  tendons  can  be 


LOWER   EXTREMITY.  209 

drawn  away  with  a  strong  hook.  Should  the  latter  be  difficult, 
the  tendons  are  severed  and  subsequently  sutured  in  order  to 
prevent  the  occurrence  of  pes  calcaneus.  Then  the  lower  wall 
of  the  tendon  sheath  and,  with  it,  the  joint  capsule  are  opened  as 
far  as  the  tibia,  and  at  the  posterior  margin  of  the  latter  to  the 
internal  malleolus.  Unless  this  is  done  thoroughly  the  succeed- 
ing step  is  made  difficult. 

The  next  step  is  as  follows.  The  foot  which  has  been  freed 
on  the  entire  external,  anterior,  and  posterior  circumference 
from  its  capsular  connection  with  the  fibula  and  tibia,  is  forcibly 
turned  medially  over  the  internal  malleolus,  i.e.,  it  is  luxated 
totally  inward  in  such  a  way  that  the  sole  points  upward  at  the 
inner  surface  of  the  leg  and  the  inner  margin  of  the  foot  touches 
the  inner  margin  of  the  tibia,  as  shown  in  Fig.  92. 

In  this  manner  we  gain  an  absolutely  unobstructed  view  into 
the  joint ;  nothing  remains  to  be  done  but  to  sever  the  ligaments 
at  the  projecting  tip  of  the  internal  malleolus  (carefully,  lest 
we  injure  the  tendons  descending  behind  the  malleolus)  to  per 
mit  inspection  of  all  the  recesses  of  the  articulation.  It  will 
then  be  easy  to  clear  the  joint  and  resect  the  talus.  If  the 
latter  is  to  be  preserved,  we  must  guard  against  unnecessary 
opening  of  the  talo-calcaneal  joint,  sparing  the  capsular  attach- 
ments at  the  posterior  and  lateral  circumference  of  the  talus. 

The  method  described  preserves  the  ligamental  apparatus  on 
the  medial  side  and  the  support  of  the  external  malleolus  on  the 
outer  side,  and  therefore  guards  as  well  as  possible  against 
lateral  deviations  of  the  foot. 

184.  Total  Tarsal  Resection  (Figs.  93  and  94).— Wladi- 
miroff  and  Mikulicz  have  added  to  our  measures  for  the  preser- 
vation of  the  foot,  even  in  very  extensive  disease,  a  procedure 
used  by  them  in  affection  of  the  posterior  tarsal  bones  and 
joints.  In  such  a  case  we  believe  the  method  to  be  superfluous, 
provided  the  soft  parts  of  the  sole  and  heel  can  be  preserved. 
But  aside  from  this  the  method  is  especiall}^  valuable  in  disease 

14 


210     •  OPEEATIVE   SURGERY. 

of  all  the  tarsal  joints  or  bones.  It  enables  us  even  in  such  a 
case  to  preserve  a  foot  useful  without  prothesis  by  attaching, 
after  excision  of  the  entire  tarsus,  the  sawed  bases  of  the  meta- 
tarsal bones  to  the  sawed  surface  of  the  leg  bones,  the  foot  being  in 
vertical  position  (in  the  prolonged  axis  of  the  leg).  The  patient 
walks  on  the  anterior  surface  of  the  heads  of  the  metatarsals, 
the  toes  being  forcibly  dorsoflected.  If  the  navicular  and  cuboid 
bones  can  be  sawed  off,  or  the  latter  divided  with  the  cuneiform 
bones,  a  broader  and  firmer  sawed  surface  is  obtained. 

In  the  same  way  as  Pirogoff  turns  the  posterior  segment  of 
the  foot  90°  and  attaches  it  as  a  prolongation  to  the  leg,  so  does 
this  method  with  the  anterior  segment. 

Since  Mikulicz's  method  starts  with  a  presupposed  defect  of 
the  skin  of  the  heel — i.e.,  with  quite  a  special  case  in  which  the 
direction  of  the  incision  is  a  natural  result — we  prefer  to  de- 
scribe the  method  for  the  typical  case  of  disease  of  the  entire 
tarsus  with  a  useful  integument. 

Incision  quite  analogous  to  that  for  posterior  tarsal  resec- 
tion, in  the  form  of  a  lateral  posterior  curved  incision,  beginning 
as  in  Fig.  93  a  hand's  breadth  above  the  ankle  joint,  extending 
downward  behind  the  external  malleolus  and  the  peroneal  ten- 
dons to  the  middle  of  the  fifth  metatarsus.  In  the  above- 
described  manner  the  bones  and  joints  between  the  leg  and 
metatarsus  are  exposed,  the  Achilles  tendon  being  detached  with 
the  periosteum  of  the  calcaneus,  and  the  peroneal  tendons  lifted 
from  their  sheath  and  drawn  forward.  The  vessels  and  nerves 
are  preserved,  the  tendinous  attachments  of  all  the  long  foot 
muscles  (peroneus  tertius,  brevis,  and  longus)  are  separated  from 
the  upper,  outer,  and  lower  surface  of  the  metatarsal  bones, 
and  the  attachments  of  the  tibialis  anticus  and  posticus  from 
the  upper,  medial,  and  lower  surface  of  the  same  bones. 

185.  Resection  of  the  Lower  Third  of  the  Leg  (Fig.  95). — 
In  the  case  of  extensive  disease  in  the  lower  third  of  the  leg 
bones,  an  attempt  should  be  made,  if  possible,  to  expose  the  dorsal 


LOWER   EXTREMITY. 


211 


surface  of  the  tuber  calcanei  by  a  very  long  latero -posterior  in- 
cision and  to  attach  it  to  the  correspondingly  freshened  sawed 
surface  of  the  tibial  diaphysis. 

186.  Resection  of  the  Tibia. — In  a  case  in  which  an  exten- 


FiG.  95.— Resection  of  the  Leg  (Lower  Third).        Fig.  94. —  Case  of  Total  Tarsal  Resection;  Personal  Ob- 
servation (after  a  Photograph). 


sive  portion  (the  middle  third)  of  the  tibial  diaphysis  had  to  be 
resected  for  necrosis,  the  diaphysis  of  the  fibula  on  the  other 
side  was  removed  by  us  and  inserted  into  the  excavated  remnant 
of  the  tibia. 

187.  Resection  of  the  Fibula. — The  diaphysis  and  even  the 


212 


OPERATIVE    SURGERY. 


whole  fibula  can  be  removed  by  an  incision  behind  the  peroneal 
muscles  in  their  entire  length,  without  damaging  the  usefulness 
of  the  leg  for  support  or  locomotion  or  imjDairing  the  movements 
of  the  foot  in  any  direction.  At  the  upper  end  we  must  pre- 
serve the  peroneal  nerve  which  curves  around  the  neck,  in  the 

lower   half  the  peroneal  artery   which 
passes  behind  the  fibula. 

188.  Artlirotomy  and  Resection  of 
the  Knee  (Figs.  96,  97,  98).— Numer- 
ous methods  for  free  opening  of  the 
knee  joint  have  been  devised,  all  of 
which  we  have  tested.  None  of  them 
however,  gives  absolutely  sufficient  ac- 
cess in  so  simple  a  manner  as  the  trans- 
verse incision  with  lower  convexity;  to 
be  sure,  it  must  be  carried  laterally  far 
enough  backward  to  embrace  at  least 
two-thirds  of  the  circumference  of  the 
knee.  It  is  not  quite  clear  to  which 
surgeon  belongs  the  merit  of  its  intro- 
duction, as  Park  appears  to  have  made 
the  proposition  and  Textor  is  named  as 
the  father  of  the  method.  At  all  events 
Erichsen  seems  to  have  contributed  to 
its  general  acceptance.  It  is  certain, 
however,  that  after  the  skin  has  been  divided  by  a  transverse 
incision,  the  subsequent  steps  of  the  operation  have  been  per- 
formed in  widely  varying  ways.  It  is  the  latter  which  deter- 
mine the  final  result. 

Different  procedures  are  required  for  arthrotomy  and  arthrec- 
tomy  of  the  knee  joint  and  for  resection ;  for,  contrary  to  all 
other  joints,  in  resection  we  aim  at  ankylosis  (in  good  position), 
while  in  arthrotomy  the  possibility  of  recovery  with  mobility  is 
to  be  kept  in  view. 


. — Resection  of  the  Knee. 


LOWER   EXTREMITY. 


213 


Resection  of  the  Knee.— In  a  case   of   knee-joint   disease 
doomed  ah  initio  to  resection,  the  skin  and  especially  the  tense 


Capsular  incision  under  the  condyles 

Capsular  incis'n  beside  patella  &  ligament 


Quadriceps  tendon 


Vastus  ex-     |       Fascia  lata 
ternus  m.    Ligamentum  pateilse 
Vastus  internus  muscle 
Fascia  lata 

Fig   97.— Arthrectomy  of  the  Knee. 

Patella  turned  over 

Medial  layer  of  fat 
Ligamentum  patellae 
Lateral  layer  of  fat 


Fig.  98.— Arthrectomy  of  the  Knee. 


fascia  lata  are  divided  transversely  and  dissected  up  above  the 
patella.     The  tendinous  expanse  of  the  vasti  together  with  the 


214  OPERATIVE    SURGERY. 

stout  quadriceps  tendon  is  divided  by  an  incision  curving  around 
the  upper  circumference  of  the  patella,  but  reaching  only  to  the 
outer  surface  of  the  capsule.  The  latter  is  then  traced  upward, 
outward,  and  backward  along  its  outer  surface  to  its  attach- 
ment and  reduplication  at  the  femur ;  with  the  visceral  serosa 
it  is  dissected  from  the  bone  as  far  as  the  cartilaginous  margins 
of  the  femur  on  the  whole  outer  surface,  also  backward  below 
the  condyles,  the  attachment  of  the  lateral  ligaments  being- 
separated.  In  like  manner  the  tendinous  fascia  is  dissected 
downward  until  the  attachment  of  the  capsule  to  the  tibia  is 
completely  exposed  from  without.  During  this  step  the  liga- 
mentum  patellae  and  the  lower  attachment  of  the  lateral  liga- 
ments are  severed.  Then  the  capsule  is  here,  too,  separated  all 
around  from  the  margin  of  the  tibia  to  the  cartilaginous  sur- 
faces and  the  menisci  divided  at  the  same  time.  In  this  way 
the  entire  anterior  and  lateral  surface  of  the  capsule  with  the 
covering  patella  and  the  ligamentum  patellae  are  withdrawn  in 
connection  like  a  tumor,  without  the  necessity  of  cutting  into 
morbid  tissue. 

Most  surgeons  make  it  a  rule  to  continue  the  transverse  in- 
cision at  once  into  the  joint,  the  ligamentum  patellae  being 
severed.  It  is  obvious  that  this  is  no  advantage  in  infectious 
and  particularly  tuberculous  effusions  into  the  joint;  and  as  in 
this  procedure  the  patella  v/ith  the  quadriceps  retracts  upward, 
the  excision  of  the  pouch  under  the  quadriceps  is  rendered 
more  difficult  as  compared  with  our  method. 

We  always  remove  not  only  the  patella,  but  we  also  divide 
the  crucial  ligaments  and  excise  the  menisci  and  ligaments. 
OUier's  subcapsulo -periosteal  method  is  not  justified  here  for 
any  surgeon  who  aims  at  ankylosis  of  the  knee.  The  patella 
and  its  ligament  as  well  as  accessory  ligaments  contribute  com- 
paratively little  to  the  firmness  of  the  joint,  and  everything 
depends  upon  securing  a  very  firm  union  of  the  bones  so  as  to 
obtain  a  perfectly  useful  extremity.     If  this  is  not  effected,  the 


LOWER   EXTREMITY.  215 

results,  as  a  rule,  will  remain  defective  despite  patella  and  liga- 
ments. This  is  apparent  even  from  the  fact  that  when  anky- 
losis results  in  young  patients  after  pure  arthrectomy  with 
preservation  of  the  entire  extensor  apparatus,  strongly  flexed 
positions  are  secured,  fully  equal  to  those  after  resection  in 
which  the  entire  joint  with  the  patella  has  been  extirpated.  For 
this  reason  we  do  not  use  Volkmann's  transverse  incision  through 
the  patella,  particularly  because  we  agree  with  Bockel  that  the 
patella  itself  is  but  too  often  involved  in  the  disease. 

Therefore,  contrary  to  Oilier,  we  here  positively  avoid  the 
subperiosteal  operation  and  make  the  simplest  jDossible  wound, 
covering  the  exposed  and  sawed  bones  merely  with  skin,  fascia, 
and  muscle;  for,  as  we  have  stated,  we  have  learned  to  rely 
absolutely  on  the  bony  ankylosis.  Not  that  we  have  failed  to 
observe  that  the  contraction  of  the  quadriceps  is  preserved ;  but 
in  ankylosis  of  the  knee  the  vasti  no  longer  produce  any  result, 
and  the  rectus  femoris  inverts  its  effect  and  acts  merely  on  the 
thigh  as  a  flexor  in  the  hip  joint. 

Eoom  having  been  made  by  the  excision  of  the  entire  anterior 
and  lateral  walls  of  the  joint,  it  is  easy  to  extirpate  the  posterior 
wall  during  strong  flexion.  To  this  end  the  crucial  ligaments 
must  be  separated,  best  at  their  attachment  in  the  intercondyloid 
fossa  or  close  to  the  bone  at  the  adjoining  condyloid  surfaces  of  the 
femur.  Then  we  can  reach  the  dorsal  surface  of  the  condyles 
of  the  femur  and  tibia  and  effect  the  exact  removal  of  the 
macroscopically  diseased  tissue,  possibly  also  excise  in  toto  some 
mucous  bursse,  especially  the  popliteal.  A  clean  wound  surface 
remains  which  is  thoroughly  disinfected  before  the  bones  are 
sawed  off,  or  dusted  with  iodoform  in  tuberculosis  so  as  to  pre- 
vent the  further  development  of  infectious  materials  left  behind. 

In  view  of  the  expected  firm  ankylosis  of  exactly  coapted 
bones,  a  very  essential  point  is  the  manner  in  which  the  bones 
are  sawed.  In  order  to  prevent  the  forward  displacement  of 
the  femur  on  the  tibia,  all  sorts  of  angular  cuts  have  been  made 


216  OPERATIVE   SURGERY. 

on  the  one  hand,  and  attempts  at  fixation  between  the  sawed 
surfaces  on  the  other  hand.  Nails  have  been  used  for  fixation 
or  sutures  have  been  appHed.  But  as  these  often  tore  out  and 
failed  to  answer  the  purpose,  Albert  of  Vienna  and  others  have 
made  angular  cuts.  We  as  well  as  Metzger  and  Fenwick  have 
succeeded  best  by  sawing  the  femur  convex  and  the  tibia  corre- 
spondingly concave.  The  latter  author  attaches  great  value  to 
the  method,  as  shown  in  a  paper  published  in  1871,  and  subse- 
quently he  reported  twenty -eight  cases  with  very  good  func- 
tional results.  Of  course  the  surgeon  must  be  master  in  the 
handling  of  the  saw,  but  then  the  two  surfaces  can  be  so  fitted 
together  that  any  further  artificial  fixation  becomes  quite  un- 
necessary ;  provided,  however,  that  the  leg  is  fastened  to  a  splint 
in  complete  extension.  The  curved  sawing  of  the  femur  has 
another  advantage  in  that  its  epiphyseal  line,  which  determines 
the  future  growth,  is  most  certainly  preserved.  After  the  bones 
are  coapted,  a  simple  deep  cutaneous  suture  is  inserted,  drainage 
tubes  having  been  passed  through  special  openings.  In  numer- 
ous cases  during  the  last  tew  years  we  have  obtained  by  this 
operation  perfect  adhesion  by  first  intention  as  in  simple  wounds 
of  the  soft  parts,  so  that  in  one  or  two  weeks  a  permanent  sili- 
cate-of-soda  dressing  could  be  applied  as  for  simple  subcutaneous 
fracture,  and  the  patient  could  get  up  six  weeks  after  the  oper- 
ation. 

Arthrotomy  of  the  Knee. — As  resection  of  the  knee  differs 
from  the  type  described  for  resections  in  general,  special  men- 
tion must  be  made  of  the  method  in  which  ankylosis  is  not 
desired.  In  cases  of  arthrotomy  and  arthrectomy  in  which 
there  is  any  prospect  of  a  movable  joint  we  have  come  to  the 
conclusion,  after  various  experiments,  that  every  breach  in  the 
continuity  of  the  extensor  apparatus  of  the  knee  joint  is  harm- 
ful. No  matter  how  exact  is  the  suture  of  the  ligamentum 
patellae,  of  the  patella,  or  of  the  quadriceps  tendon,  or  how  good 
is  the  course  of  the  wound,  we  can  never  expect  or  attain  as 


LOWER   EXTREMITY.  217 

rapid  and  vigorous  contractions  of  the  quadriceps  as  when  that 
muscle  with  its  tendinous  apparatus  has  been  kept  quite  intact 
as  far  as  the  sjjine  of  the  tibia.  And  this  latter  mode  can  be 
executed  even  in  very  extensive  disease  without  greatly  com- 
plicating the  operation  and  especially  without  diminishing  the 
certainty  that  all  morbid  parts  of  the  joint  will  be  removed. 
We  proceed  in  the  following  manner: 

Anterior  curved  incision,  beginning  latero-posteriorly  over 
the  line  of  the  joint,  extending  through  skin  and  fascia,  which 
are  detached  as  flaps  from  the  anterior  surface  of  the  patella 
and  its  ligament,  as  in  resection.  But  instead  of  severing  the 
quadriceps  tendon  transversely  above  the  patella,  we  expose 
obliquely  upward  the  margin  of  the  vastus  internus  and  ex- 
ternus.  Then  we  divide  the  capsule  at  the  margin  of  the 
patella  alongside  of  the  latter  and  the  ligamentum  patellae, 
separate  its  attachment  to  the  femur  externally  and  posteriorly 
(Fig.  97),  together  with  the  attachment  of  the  internal  and 
external  ligaments  to  the  femur  to  a  point  behind  and  above 
the  condyles,  and  turn  the  capsule  downward.  Now  the  patella 
can  be  easily  luxated  first  laterally,  then  medially,  and  the 
joint  opened  wide  enough  to  permit  inspection  of  its  greater 
portion.  If  all  the  folds  are  to  be  inspected,  we  must  separate 
the  attachments  of  the  crucial  ligaments  between  the  condyles 
of  the  femur  as  during  resection.  Then  all  the  recesses  of  the 
joint  are  open  to  view.  The  last-named  ligaments  remain  in 
connection  with  the  tibia  below,  and  above  with  the  periosteum 
of  the  dorsal  surface  of  the  femur,  and  therefore  adhere  in  good 
position.  According  to  requirements  we  can  now  extirpate  the 
entire  synovial  membrane  or  excise  circumscribed  patches. 
Finally  the  patella  is  turned  over  and  freed  from  adhering  fun- 
gous granulations,  or  diseased  bone  is  thoroughly  removed,  and 
the  posterior  surface  of  the  quadriceps  tendon  cleared  of  any 
remnants  of  the  diseased  bursa.  If  the  popliteal  and  semi- 
membranosa  bursse   are   degenerated,  they  can  be  cleaned  in 


218  OPERATIVE    SURGERY. 

the  same  manner.  The  cartilages  are  cut  off  whenever  or 
wherever  they  are  at  all  discolored  or  softened  by  penetrating 
granulations.  Special  care  should  be  taken  lest  diseased  patches 
in  the  bone  be  overlooked,  for  they  must  be  thoroughly  scraped 
out. 

Where  the  capsule  has  been  preserved  it  is  carefully  sutured, 
then  the  flaps  of  skin  and  fascia  are  brought  in  contact  by  some 
deep  sutures,  and  after  the  insertion  of  drainage  tubes  the  con- 
tinuous cutaneous  suture  is  applied.  In  order  to  insure  perma- 
nent recovery  in  tuberculosis,  iodoform  is  dusted  in;  or  else, 
after  temporary  iodoform  tamponade,  we  may  follow  the  method 
recommended  by  us  and  recently  somewhat  modified  by  Berg- 
mann,  Sprengel,  Helferich,  and  others;  namely,  cutting  a  few 
primary  temporary  deep  sutures,  and  inserting  an  exact  unin- 
terrupted secondary  suture  after  the  lapse  of  twenty-four  or 
even  forty-eight  hours.  By  that  time  all  after-hemorrhages 
have  ceased.  The  temporary  sutures  have  the  advantage  of 
preventing  the  retraction  of  the  skin  and  fascia. 

Irregular  resections  and  excisions  of  the  knee  joint,  for  in- 
stance, of  one  condyle  of  the  tibia  or  femur,  are  permissible  only 
when  we  are  sure  of  an  ankylotic  union  of  the  remaining 
condyle  with  the  opposite  bone. 

189.  Resection  of  the  Patella. — In  primary  disease  of  the 
patella  this  is  an  important  operation  for  the  prevention  of 
diffuse  affection  of  the  joint.  Longitudinal  incision,  separation 
of  the  covering  quadriceps  fascia  and  periosteum,  and  enuclea- 
tion from  the  anterior  wall  of  the  capsule  are  the  several  steps 
of  this  simple  operation.  Its  results  are  very  satisfactory,  for 
perfect  mobility  of  the  joint  may  be  preserved  (see  reports  by 
Dr.  Kummer). 

190.  Osteotomy  and  Cuneiform  Resection  of  the  Tibia  (Fig. 
99). — Transverse  incision  {i.e.,  in  the  cleavage  line  of  the  skin) 
two  fingers'  breadth  below  the  line  of  the  joint,  extending  from 
the  spine  of  the  tibia  to  the  eminence  of  the  calf  muscles;  the 


LOWER  extke:.iity.  219 

periosteum  is  detached  and  the  chisel  applied  in  the  direction  of 
the  cutaneous  incision.  The  attachments  of  the  ligamentum 
patellae  must  not  be  injured,  for  between  it  and  the  tibia  is  a 
bursa  mucosa  which  may  communicate  with  the  joint. 

In  pronounced  genu  valgum  it  is  preferable  to  excise  a 
wedge  from  the  tibia  whose  base  should  be  directed  medially ; 
otherwise,  during  straightening,  there  may  be  too  much  drag- 
ging upon  the  head  of  the  fibula  with  consequent  paralysis  of 
the  peroneal  nerve  which  surrounds  it. 

191.  Sujoracondylic  Osteotomy  of  the  Femur  (Fig.  99). — 
The  incision  which  follows  the  cleavage  line  of  the  skin  is  oblique 
both  externally  and  internally,  passing  forward  interiorly  from 
above  posteriorly,  through  the  skin  and  fascia  lata,  which  is 
very  thick,  especially  on  the  outer  side.  The  vastus  (internus 
or  externus)  is  freed  at  its  posterior  margin  and  drawn  upward ; 
the  periosteum  is  divided  from  the  condyle  upward  and  sepa- 
rated in  front  and  behind ;  the  bone  is  cut  with  the  chisel  for 
three-fourths  of  its  thickness  and  the  rest  broken. 

The  superior  internal  or  external  artery  of  the  knee  joint 
must  be  borne  in  mind,  on  the  inside  especially  the  deep  branch 
of  the  arteria  articularis  genu  suprema.  Next  to  Macewen, 
who  developed  this  method  into  the  normal  procedure  for  genu 
valgum,  we  were  the  first  to  perform  osteotomy  of  the  femur 
for  this  affection. 

192.  Osteotomy  and  Siihtrochanteric  Cuneiform  Resection 
of  the  Femur  (Figs.  100  and  101). — Transverse  incision  through 
the  skin,  the  fascia  of  the  glutseus  maximus,  and  the  tendinous 
attachment  of  the  vastus  externus  muscles  to  the  bone  at  the 
outer  side,  at  the  level  of  the  base  of  the  great  trochanter,  so 
that  the  trochanter  minor  remains  above  the  line  of  division. 
The  terminal  branch  of  the  external  circumflex  artery  runs 
parallel  to  the  incision  (see  Ligations).  The  bone  is  cut  with 
the  chisel  obliquely  from  above  postero-externally  to  below 
antero-internally  in  order  to  prevent  dislocation  of  the  lower 


220 


OPERATIVE    SURGERY. 


fragment  medially  or  forward  from  above,  during  forced  ab- 
duction. 

The  operation  is  performed  for  the  correction  of  adduction, 
flexion,  and  shortening  following  coxitis  that  has  healed  in  bad 
position,  also  for  old  and  congenital  luxations  of  the  hip  joint. 


^IG.  99.— Osteotomy  of  the  Fe- 
mur. Cuneiform  Osteotomy 
of  the  Tibia. 


Fig.  100.  Fig.  101. 

Figs.  100  and  101.— Subtrochanteric  Osteotomy. 


After-treatment  in  forced  abduction  with  elevated  pelvis  and 
plaster  dressing  with  double  stocking. 

193.  Resection  of  the  Diaphysis  of  the  Femur. — Incisions 
can  be  made,  without  fear  of  incidental  injury,  on  the  outer 
side  through  the  whole  length  of  the  bone,  from  the  base  of  the 
great  trochanter  (where  the  terminal  branch  of  the  external 
circumflex   artery   passes   under   the   vastus)    to   the   external 


LOWER   EXTREMITY. 


221 


condyle  of  the  femur  (where  the  external  superior  artery  of  the 
knee  joint  runs  transversely  around  the  bone,  at  the  posterior 
margin  of  the  vastus  externus,  between  it  and  the  biceps 
muscle). 


Resection  of  the  pelvis 


Arthrectomy  and  re-  / 
section  of  the  hip    ) 


Fig.  103. 


194.  Resection  of  the  Hip  (Figs.  102,  103,  and  104).— Angu- 
lar incision,  beginning  at  the  base  of  the  outer  surface  of  the 
great  trochanter,  passing  obliquely  upward  to  the  anterior  point 
of  the  trochanter,  thence  bending  at  an  angle  in  the  direction 
of  the  fibres  of  the  glutseus  maximus,  and  extending  obliquely 
upward  and  medially  through  the  skin  and  the  often  abundant 


222 


OPEEATIVE   SURGERY. 


adipose  tissue.  Usually  at  the  base  of  the  great  trochanter 
larger  branches  of  the  external  circumflex  artery  are  cut  and 
ligated.  On  the  outer  surface  of  the  great  trochanter  the  fascia 
of  the  glutseus  maximus  muscle  is  severed,  thus  exposing  the 


Crlutseus  maximus  muscle 


Glutseus  medius 
muscle 


Pyriformis  muscle 
Great  trochanter 

Obturator  internus 
muscle 

Quadratus  f  emoris 
muscle 


Fig.  103.— Resection  of  the  Hip. 

periosteum  and  the  attachment  of  the  gluteus  medius  muscle 
which  covers  the  whole  of  the  tip  of  the  trochanter. 

Upward  and  backward  the  incision  divides  the  fibres  of  the 
glutseus  maximus,  and  usually  in  the  upper  portion  some  larger 
vessels  are  cut  and  must  be  ligated. 

The  layer  of  fat  thus  laid  bare  is  separated,  and  at  the  lower 


LOWER   EXTREMITY. 


223 


margin  of  the  glutseus  medius  we  reach  the  interstice  between 
this  muscle  and  the  glutseus  minimus  above  and  the  pyriformis 
below.  Entering  here  and  drawing  the  pyriformis  down,  we 
immediately  strike  the  posterior  surface  of  the  capsule  of  the 


GlutfBus  maximus  muscle 

Glut£Eus  medius  and  minimus  I 

muscles  \ 

Tendons  of  the  pflutei  muscle 


Great  trochanter 
Posterior  wall  of  the  capsule 
with  the  attachments  of 
the  pyriformis  and  the  ob- 
turator muscles 


Fig.  104.— Resection  of  the  Hip. 


dorsal  wall  of  the  acetabulum.  Anteriorly  we  follow  the  upper 
margin  of  the  slender  pyriformis  tendon  to  the  attachment  of 
the  glutseus  medius  to  the  great  trochanter,  and  separate  this 
forward  in  its  whole  extent  close  to  the  bone,  i.e.,  dissect  it 
away  from  the  upper  point  and  the  outer  surface  of  the  tro- 
chanter. 


224  OPEHATIVE   SURGERY. 

At  the  anterior  margin  of  the  great  trochanter  we  separate 
the  tendon  of  the  glutseus  minimus  with  the  glutseus  medius  and 
draw  these  muscles  forward  with  hooks.  From  the  inner  sur- 
face of  the  great  trochanter  and  the  trochanteric  fossa  we  sepa- 
rate the  tendons  of  the  pyriformis,  the  obturator  and  gemelli, 
and  finally  the  obturator  externus,  and  lift  these  tendons  with 
the  periosteum  from  the  inner  and  posterior  surface  of  the  tro- 
chanter, drawing  them  backward  en  masse. 

In  this  way  the  muscles  supplied  by  the  superior  gluteal 
nerve,  viz.,  the  glutaeus  medius  and  minimus,  are  crowded  for- 
ward and  upward  toward  the  tensor  fasciae  muscle,  which  is 
supplied  by  the  same  nerve  and  is  of  special  importance  for  the 
subsequent  abduction  of  the  thigh ;  while  the  rest  of  the  mus- 
cles, glutaBus  maximus,  pyriformis,  and  obturators,  which  are 
mainly  supplied  by  the  inferior  gluteal  nerve,  remain  below. 
To  be  sure,  the  pyriformis  muscle  receives  now  and  then  a  twig 
from  the  superior  gluteal  nerve,  but  in  that  case  the  branch  is 
given  off  so  high  up  that  its  injury  is  out  of  the  question. 

Thus  the  whole  posterior  surface  of  the  head  and  neck  of  the 
femur  is  laid  bare,  with  as  much  of  the  trochanter  as  is  required, 
and  we  merely  have  to  ligate  some  branches  of  the  circumflex 
arteries  which  run  transversely  oVer  the  capsule  of  the  neck  and 
possibly  the  external  circumflex  at  the  base  of  the  great  tro- 
chanter, where  it  passes  through  the  vastus  externus  and  around 
the  femur.  If  fungous  granulations  on  the  synovial  membrane 
necessitate  its  excision,  it  will  not  be  difficult  to  dissect  it  out 
for  quite  a  distance  from  behind,  before  it  is  opened ;  to  separate 
it  from  its  attachment  to  the  acetabulum  and  the  neck  of  the 
femur,  and  to  remove  the  j)osterior  wall  in  toto.  The  thigh 
being  strongly  adducted,  rotated  inward,  and  flexed,  the  liga- 
mentum  teres  is  detached  and  the  head  luxated  backward,  and 
in  this  position  the  acetabulum  is  open  to  inspection.  Fun- 
gosities  are  removed  with  forceps  and  scissors  until  the  joint  is. 
thoroughly  cleared. 


UPPER   EXTREMITY. 


225 


Among  the  numerous  methods  for  the  resection  of  the  hip 
joint  we  know  of  none  which  is  ecjually  conservative  regarding 
muscles,  nerves,  and  bone,  and  affords  as  thorough  an  inspec- 
tion of  the  joint.  It  is  a  further  development  of  Langenbeck's 
method,  on  whose  oblique  incision  it  is  based,  but  which  does 
not  suffice,  especially  for  the  extirpa- 
tion of  the  capsule  alone  with  preser- 
vation of  the  bone.  Hence  we  abstain 
from  making  comparisons  with  other 
modes  of  operation. 

If  arthrotomy  alone  is  intended,  the 
muscular  attachments  to  the  trochanter 
are  not  first  separated,  but  the  capsule 
is  opened  at  once  along  the  upper  mar- 
gin of  the  acetabulum  as  far  as  the 
neck  of  the  femur,  and  with  the  cap- 
sule the  periosteum  and  muscular  at- 
tachments are  separated  from  the  neck 
and  the  trochanter. 

195.  Resection  of  One- Half  of  the  Pel- 
vis (Fig.  102). — Performed  by  Kocher 
and  Roux  with  very  satisfactory  func- 
tional result,  so  that  my  patient,  in 
whom  the  head  of  the  femur  was  resected  at  the  same  time, 
can  walk  without  a  cane,  though  he  limps  badly.  We  give  a 
characteristic  illustration  from  a  photograph  taken  three  and 
a  half  years  after  the  operation. 


Fig.  105. 


V.  Upper  Extremity. 


196.  Excision  of  the  Phalanges,  Metacarpal  Bones,  Inter- 
phalangeal  and  Metacarpo-phalangeal  Joints  (Figs.  100  and 
107). — For  the  phalanges  and  joints  only  lateral  incisions,  for 
the  metacarpals  dorsal  incisions,   come  in  question.     Incisions 


15 


326 


OPERATIVE    SURGERY. 


on  the  fingers  are  placed  nearer  the  dorsum,  and  this  all  the 
more  in  proportion  as  they  are  lengthened  peripherally. 

Eegarding  the  fingers  it  is  necessary  to  make  bilateral  inci- 
sions in  order  to  prevent  cicatricial  retraction  and  lateral  curva- 
tures after  the  removal  of  bones.  Extensor  tendons  and  nerves 
on  the  dorsum  of  the  hand  (radial  and  ulnar  nerves)  are  to  be 


Fig.  106. 


Fig.  lur. 


Figs.  106  and  107. — Resection  of  the  Phalanges  and  Metacarpals.    Resection  of  the  Articulations 
of  the  Fingers.    Frontal  Section  of  the  Wrist  Joint  after  Henle. 


spared ;  the  incisions  are  to  be  made  on  the  bones  as  felt  subcu- 
taneously  and  carried  beyond  the  adjoining  articulations. 

Where  there  is  no  contra-indication,  the  resection  should  be 
subperiosteo-capsular,  and  the  head  of  the  bone  is  to  be  exposed 
first  because  it  can  be  made  more  easily  movable. 

On  the  metacarpal  bone  of  the  thumb  the  tendon  of  the  ex- 
tensor brevis  with  the  periosteum  is  to  be  pushed  to  one  side, 
and  the  thenar  muscles  to  the  other  side ;  at  the  upper  end  of 


UPPER  EXTREMITY.  227 

the  bone  the  attachment  of  the  tendon  of  the  abductor  longus 
must  be  separated.  On  the  remaining  metacarpals  the  external 
and  internal  interosseal  muscles  are  to  be  detached  with  the 
periosteum.  Only  the  metacarpo-carpal  joint  of  the  thumb  is 
isolated ;  the  others  are  connected  with  the  wrist  joint. 

197.  Resection  of  the  Hand  (Figs.  108  and  109). — For  free 
opening  of  the  wrist  joint  we  have  generally  employed  the 
method  known  as  Langenbeck's,  which  is  probably  used 
most  largely.  Farabceuf  states  that  the  dorso-radial  incision 
had  been  introduced  in  1869  by  Bockel.  We  have  practised  the 
same  incision  before  Langenbeck's  time,  not  only  on  the  living 
patient,  but  have  demonstrated  it  on  the  cadaver  in  our  courses 
of  instruction.  At  all  events  it  was  Langenbeck  who  secured 
recognition  for  the  method,  which  has  great  advantages  over 
earlier  procedures. 

Dorso-radial  Incision. — The  hand  being  in  strong  ulnar 
flexion,  we  make  a  straight  incision  through  the  skin  from  the 
middle  of  the  second  metacarpal  to  a  point  at  an  equal  distance 
above  the  middle  of  the  wrist  joint,  in  the  axis  of  the  forearm. 
The  incision  lies  between  the  tendons  of  the  extensor  digitorum 
communis,  with  the  extensor  indicis  proprius  on  the  one  side 
and  the  extensor  jDollicis  longus  on  the  other  side.  The  skin  is 
divided  slowly,  preserving  peripherally  the  branches  of  the  super- 
ficial radial  nerve  which  pass  to  the  middle  finger;  then  we 
sever  the  common  dorsal  ligament  of  the  wrist  with  the  fascia 
and  penetrate  at  the  forearm  to  the  radius,  at  the  wrist  joint 
through  its  capsule  and  downward  to  the  base  of  the  third  met- 
acarpal. On  the  latter  we  detach  the  tendon  of  the  radialis  ex- 
tensor brevis,  and  at  the  base  of  the  second  metacarpal  that 
of  the  radialis  extensor  longus  with  the  periosteum ;  we  expose 
the  dorsal  surface  of  the  second  metacarpal  with  the  interosseal 
muscles  between  the  latter  and  the  third  metacarpal,  and  later- 
ally close  to  the  bone  we  begin  to  lift  the  tendons  out  of  their 
grooves  and  to  separate  the  capsule  of  the  wrist  joint. 


328 


OPERATIVE   SURGERY. 


The  method  of  Bockel  and  Langenbeck,  however,  has  this 
drawback,  that  in  order  to  gain  room  the  external  radial  mus- 
cles must  be  detached.  No  matter  how  carefully  we  make  the 
method  a  subperiosteal  one — as  Trelat  puts  it  (Faraboeuf),  peel- 
ing between  tree  trunk  and  bark— it  entails  grave  injury  to  the 
chief  dorsal  flexors  of  the  hand,  and  this  may  be  the  reason 
why  a  volar  subluxation  of  the  hand  with  greatly  restricted 
dorsal  flexion  so  often  results.     It  is,  therefore,  justifiable,  in 


Extensor  digitorum  communis  muscle 
Extensor  digiti  V.  muscle 

Ulna 

Ligamentous  disc 
Semilunar  bone 

Dorsal  ligament  of  the  wrist 
Unciform  bone 

Fig.  108. — Arthrotomy  and  Resection  of  the  Hand. 

view  of  these  common  disturbances,  to  be  more  sparing  of  the 
radial  muscles  and  place  the  incision  on  the  ulnar  side  of  the 
flexor  tendons,  though  still  on  the  dorsum,  i.e.,  to  use  the  dorso- 
ulnar  incision  (Figs.  108  and  109),  as  it  is  called.  This  incision, 
proposed  by  Lister,  lies  far  more  to  the  ulnar  side,  between 
flexor  and  extensor  carpi  ulnaris.  It  should  be  7  to  8  cm.  in 
length ;  it  begins,  the  hand  being  in  slight  radial  flexion,  at  the 
middle  of  the  interspace  between  the  fourth  and  fifth  meta- 
carpal, passes  toward  the  middle  of  the  wrist  joint  and  thence 
upward  in  the  middle  line  of  the  dorsal  surface  of  the  forearm. 
At  its  lower  end  the  incision  preserves  the  dorsal  branch  of  the 
ulnar  nerve,  which  is  easier  than  to  save  the  radial  in  the  dorso- 
radial  incision,  because  the  ulnar  nerve  turns  toward  the  middle 


UPPER   EXTREMITY. 


229 


line  farther  down.  The  incision  divides  the  fascia  and  the  com- 
mon dorsal  ligament  of  the  wrist,  opens  the  capsule  at  the  base 
of  the  fourth  metacarpal  upon  the  unciform  bone  and  ulna,  but 
preserves  the  tendons  of  the  extensor  digiti  minimi  proprius  and 
extensor  communis  between  which  it  passes.     The  capsule  is 


styloid  process  of  the  ulna         Lieamentous  disc  ^^^^j^g 

''*^     IJnper  row  of  carpal  bones 

'^jf^j^^H^^ -^s  magnum 

\J^'^  <^^'  rX Tnciform  bone 

Extensor  digiti  V  , 


Fig.  109.— Artlirotomy  and  Resection  of  the  Hand. 


separated  toward  both  sides  and  with  it  the  tendon  of  the  exter- 
nal ulnar  muscle  at  the  fifth  metacarpal. 

The  detachment  of  the  external  ulnar  tendon  is  less  harmful 
than  that  of  the  two  external  radials.  The  ulnar  muscle  par- 
ticipates only  to  a  minor  degree  in  dorsal  flexion  as  compared 
with  the  external  radials  which  are  attached  to  the  radio-carpal 
or  main  joint.  It  is  true,  the  external  ulnar  contributes  mate- 
rially to  ulnar  flexion ;  but  this  movement  predominates  only  too 
much  after  resection  as  a  result  of  gravity,  for  at  a  later  stage 


230  OPERATIVE   SURGERY. 

the  hand  appears  inclined  to  the  ulnar  and  volar  side  or  even  con- 
tractured  in  these  directions.  For  this  reason  the  separation  of 
that  tendon  would  act  rather  favorably  than  otherwise.  More- 
over, the  extensor  tendons  are  less  liable  to  prolapse  from  the 
wound  of  the  dorso-ulnar  incision  than  from  the  dorso-radial. 
The  extensor  tendon  of  the  little  finger  is  most  apt  to  be  in- 
jured, but  as  this  finger  is  provided  with  a  double  extensor  and 
has  far  less  important  functions  than  the  index  finger,  this  is 
of  no  importance. 

Above  on  the  ulnar  side  the  tendons  of  the  extensor  minimi 
digiti  and  the  external  ulnar  are  lifted  from  the  groove  in  the 
ulna  and  the  capsule  is  detached  round  about  the  ulna.  When 
the  joint  is  diseased  between  the  ligamentous  disc  and  the  ulna 
and  between  the  ulna  and  radius,  the  disc  must  be  excised. 
The  separation  of  the  capsular  attachments  round  about  the 
ulna  is  easy.  After  the  capsule  is  separated  from  the  fifth 
metacarpal  we  naturally  enter  the  joint  between  the  pisiform 
and  cuneiform ;  the  tendon  of  the  internal  ulnar  muscle  is  left 
intact  at  the  former  bone.  The  hamulus  of  the  unciform,  too, 
can  more  easily  be  freed  than  in  the  dorso-radial  incision.  The 
bundle  of  the  common  volar  tendons  is  readily  lifted  en  masse 
from  its  groove,  and  the  attachment  of  the  capsule  to  the  fifth, 
fourth,  and  third  metacarpals,  can  be  separated  on  the  palm, 
while  the  attachment  of  the  internal  radial  tendon  is  left  intact 
at  the  second  metacarpal.  The  tense  capsular  attachment  to 
the  volar  margin  of  the  radius  is  likewise  separated. 

On  the  dorsum  the  capsule  is  separated  from  the  dorsal  mar- 
gin of  the  lower  end  of  the  radius  to  a  point  under  the  external 
radials  and  the  extensors  of  the  thumb,  the  tendons  are  lifted 
out  of  their  grooves,  and  the  attachment  of  the  supinator  longus 
is  also  separated.  But  the  tendons  of  the  external  radials  are' 
left  attached  to  the  dorsal  surface  of  the  third  and  second  meta- 
carpals; the  hand  is  forcibly  luxated  completely  in  the  radio- 
volar  direction  so  that  the  thumb  touches  the  radial  side  of  the 


UPPER   EXTREMITY.  231 

forearm.  The  enucleation  of  the  carpal  bones  and  the  removal 
of  the  thinnest  possible  layer  from  the  bones  of  the  forearm  and 
metacarpus  now  present  no  difficulty;  only  about  the  trape- 
zium and  trapezoid  access  is  not  so  free  for  the  removal  of  these 
and  the  three  ulnar  metacarpal  bases.  In  cases  where  the 
disease  affects  mainly  the  radial  side  of  the  wrist  and  meta- 
carpals or  is  confined  exclusively  to  the  radial  side  of  the  joints, 
the  dorso-radial  method  is  preferable  to  that  described.  Be- 
tween the  trapezium  and  trapezoid,  or  between  the  bases  of  the 
first  and  second  metacarjoals,  special  attention  should  be  devoted 
to  the  radial  artery,  which  here  turns  into  the  deep  volar  arch. 

We  consider  as  essential  in  our  method  that  the  tendons  of 
the  external  radials  be .  kept  intact,  and  that  it  is  possible,  by 
complete  luxation  of  the  joint,  to  obtain  a  free  view  into  all 
recesses  and  over  all  the  bones. 

In  the  after-treatment  of  resection  and  arthrotomy  of  the 
hand  it  is  of  importance  that  dorsal  flexion  at  the  wrist  joint  be 
secured  by  a  splint  such  as  we  have  had  in  use  for  many  years, 
and  which  effects  firm  fixation  of  the  wrist  joint  while  permit- 
ting movements  of  the  fingers.  As  for  the  finer  function  of  the 
fingers  their  vigorous  flexion  alone  comes  in  question,  dorsal 
flexion  at  the  wrist  joint  is  the  only  correct  position,  for  by  the 
stretching  of  the  flexor  tendons  it  keeps  the  fingers  at  once  in 
passive  flexion  and  hence  permits  a  greater  degree  of  such 
flexion  with  very  slight  exertion. 

198.  Resection  of  the  Ulna. — The  ulna  lies  subcutaneous 
through  the  entire  length  of  the  forearm,  in  the  space  between 
the  external  and  internal  ulnar  muscle.  It  can,  therefore,  be 
partially  or  totally  excised  without  difficulty  or  incidental 
injury. 

199.  Resection  of  the  Radius. — The  radius  is  far  less  readily 
accessible  than  the  ulna.  On  the  posterior  side  of  the  radius 
the  condyle  can  always  be  felt  under  the  skin  and  therefore  can 
be  resected  from  a  portion  of  the  incision  whose  direction  and 


232  OPEKATIVE   SURGERY. 

position  are  more  fully  described  under  our  method  for  the 
resection  of  the  elbow. 

On  the  diaphj^sis  the  middle  third  is  palpable  on  the  posterior 
surface  between  the  extensores  radiales  (longus  and  brevis)  and 
the  extensors  of  the  fingers.  Incision  can  here  be  made  without 
having  to  fear  the  vessels,  nor  need  nerve  twigs  be  considered, 
since  the  adjoining  muscles  obtain  their  radial  branches  higher 
up.  The  upper  third  of  the  radius  is  covered  by  the  supinator 
brevis  through  which  the  motor  branch  of  the  radial  nerve 
passes  dorsad.  The  lower  third  is  covered  externally  by  the 
tendons  of  the  brachio-radialis  and  the  radiales  externi  which 
run  longitudinally,  by  the  pronator  quadratus,  by  the  extensors 
crossing  the  dorso-radial  side  obliquely,  and  by  the  abductor  of 
the  thumb. 

An  incision  along  the  entire  length  of  the  radius  down  to  the 
bone  is  possible  only  in  the  line  for  the  ligation  of  the  radial 
artery,  during  which  the  superficial  (sensory)  branch  of  the 
radial  nerve  is  displaced  toward  the  radial  side,  and  the  vessels 
are  pushed  to  the  ulnar  side.  For  the  nerve  lies  toward  the 
radius  above;  below,  at  the  lower  fourth  of  the  forearm,  it 
turns  to  the  dorsal  side. 

TJie  Free  Openmg  of  the  Elbow  Joint. 

200.  Besection  of  the  Elhoiv  (Figs.  110  and  111). — As  in  all 
arthrotomies  and  resections  of  the  joints  which  require  a  free 
view  into  the  joint  for  the  correct  removal  of  all  diseased  tis- 
sues, we  adhere  to  the  principle  that  a  somewhat  complicated 
cutaneous  incision  matters  little  if  thereby  we  can  preserve  not 
only  all  the  muscles  with  their  attachments,  but  especially  spare 
the  nerve  fibres  which  supply  the  muscles.  This  was  our  main 
reason  for  introducing  the  posterior  curved  incision  for  the 
arthrotomy  of  the  shoulder  to  be  described  hereafter,  and  in  the 
same  sense  we  have  modified  the  old  method  for  the  resection 
of  the  elbow. 


UPPER  EXTREMITY. 


233 


At  first  we  practised  the  simple  method  of  von  Langenbeck 
with  posterior  longitudinal  incision ;  l)ut  we  found  that  access 
was  not  as  free  as  was  desirable,  particularly  in  cases  of  fungous 
inflammations  localized  in  the  region  of  the  head  of  the  radius 


upinator  longus  muscle 
External  uoudjle 
Head  of  tlie  radius 

jrnal  ulnar  uiuscl 


Triceps  muscle  I      Ulna 

Anconseua  quartus  muscle 

Fia.  110.— Resection  of  the  Elbow. 


Supinator  longus  muscle 

I  External  condyle 

1     I         Head  of  the  radius 

Point     of     attachment 

of  the  anconeeus  IV. 

niuscletothe  ulna 


Triceps  muscle  //   I  Divided  fascia 

Attachment  of  the  ancongeus  IV.  muscle  to  the  uhia 
Fig.  111.— Resection  of  the  Elbow. 


or  extending  in  this  direction.  Such  access  is  furnished  by 
Ollier's  bayonet  incision— an  excellent  method.  But  even  the 
latter  has  the  drawback  of  placing  the  anconseus  quartus  muscle 
out  of  function.  It  is  true,  the  obhque  middle  portion  of  Ollier's 
incision  passes  through  the  interstice  between  the  external  head 


234  OPERATIVE   SURGERY. 

of  the  triceps  and  the  anconseus  quartus ;  but  since  the  branch 
of  the  radial  nerve  which  supphes  the  latter  muscle  descends 
from  above  as  the  terminal  twig  of  the  above-mentioned  branch 
supplying  the  head  of  the  triceps,  the  muscle  must  atrophy  after 
OUier's  operation.  But  in  the  case  of  the  elbow  it  is  our  partic- 
ular duty  to  do  our  best  to  secure  actively  movable  joints,  and 
for  that  reason  the  anconseus  quartus  should  be  preserved,  as  it 
is  a  true  articular  muscle  for  the  tension  and  fixation  of  the 
capsule.     This  we  effect  in  the  following  manner. 

The  elbow  is  bent  to  about  150°  and  an  angular  incision  is 
made  as  in  Fig.  110.  This  begins,  like  Ollier's  incision,  at  the 
edge  of  the  outer  surface  of  the  lower  margin  of  the  humerus, 
3  to  5  cm.  above  the  line  of  the  joint;  it  runs  essentially  parallel 
to  the  axis  of  the  humerus,  i.e.,  in  a  vertical  direction  to  the 
head  of  the  radius,  thence  corresponding  to  the  lateral  margin . 
of  the  anconaeus  quartus  to  the  edge  of  the  ulna  4  to  6  cm. 
below  the  tip  of  the  olecranon,  and.  bends  up  about  1  or  2  cm. 
on  the  medial  side  of  the  ulna.  Above,  the  incision  reaches  to 
the  lateral  edge  of  the  humerus  between  the  brachio-radialis, 
radiales  externi,  and  extensor  digitorum  communis  muscles,  all 
of  which  remain  in  front,  and  the  anconseus  brevis  which  re- 
mains behind ;  then  on  the  postero-external  circumference  of  the 
head  of  the  radius  it  severs  the  capsule  and  penetrates  down- 
ward between  the  lateral  margin  of  the  anconseus  quartus  and 
the  external  ulnar  muscle  to  the  lateral  surface  of  the  ulna. 
The  last  offshoots  of  the  anconseus  quartus  downward  at  the 
edge  of  the  ulna  are  cut,  for  frequently  they  reach  very  far 
down  the  forearm. 

Accordingly  the  incision  completely  separates  the  muscles 
supplied  by  the  forearm  branches  of  the  radial  nerve  from  those 
innervated  by  the  deep  branch  of  the  radial  nerve  at  the  fore- 
arm, and  thereby  avoids  any  subsequent  atrophy.  After  the 
bone  is  laid  bare  and  the  capsule  opened,  the  next  step  depends 
upon  the  fact  whether  the  removal  of  the  olecranon  is  required 


UPPER  EXTREMITY.  235 

or  not.  If  the  latter  is  diseased,  the  chisel  is  applied  in  the  line 
of  the  incision  without  unnecessary  detachment  of  the  muscles 
and  tendons,  and  the  olecranon  is  cut  obliquely  at  its  base  (more 
deeply  on  the  dorsal  side).  Then  the  flap  consisting  of  triceps, 
anconseus  quartus,  and  olecranon  can  ha  turned  over  toward  the 
ulna,  and  the  joint  is  open  to  inspection.  According  to  the 
extent  of  its  involvement,  the  olecranon  can  be  enucleated  in 
the  most  conservative  manner. 

If  the  olecranon  is  to  be  preserved,  we  proceed  as  follows. 
The  external  head  of  the  triceps  is  separated  from  the  humerus 
with  the  periosteum  and  the  attachment  of  the  capsule,  the 
anconseus  quartus  from  the  outer  surface  of  the  ulna,  the  at- 
tachment of  the  triceps  from  the  tip  of  the  olecranon,  and  a 
portion  of  the  internal  ulnar  muscle  from  the  inner  surface  of 
the  ulna.  This  triceps-anconseus  flap  with  the  capsule  is  turned 
inward  over  the  olecranon  like  a  cap,  the  arm  being  extended. 
As  shown  in  Fig.  Ill,  the  joint  can  now  be  freely  inspected 
from  behind  externally  and  be  made  to  gape  as  soon  as  the 
external  lateral  ligament  and  the  capsule  are  detached  from  the 
external  condyle  of  the  humerus  and  the  neck  of  the  radius. 
In  this  way  the  entire  extensor  apparatus  is  preserved  in  toto, 
as  regards  both  muscles  and  nerves.  According  to  the  indica- 
tions for  the  arthrotomy,  we  now  detach  as  gently  as  possible 
the  internal  lateral  ligament  from  the  inner  margin  of  the 
ulna  and  the  medial  surface  of  the  trochlea,  also  the  muscles, 
in  connection  with  the  periosteum,  from  behind  forward  so 
far  as  absolutely  necessary,  from  the  internal  and  external 
condyle,  when  the  resection  of  the  bone  can  be  performed  if 
required. 

In  cases  of  fungous  disease  of  the  capsule,  we  open  the  joint, 
on  principle,  as  late  as  possible,  by  carrying  the  incisions  only  as 
far  as  the  joint  capsule,  and  dissect  its  outer  surface  free.  In 
this  way  the  v/hole  morbid  mass  of  tissue  can  be  more  accu- 
rately extirpated  en  masse.     In  resection  of  the  olecranon  we 


236  OPERATIVE   SURGERY. 

have  for  many  years  practised  the  curved  sawing  in  order  to 
secure  an  olecranon  to  the  new  joint.  This  aids  largely  in  pre- 
venting forward  subluxations  of  the  forearm. 

We  have  above  laid  stress  on  the  fact  that  in  comparison  with 
the  simple  posterior  longitudinal  incisions,  of  which  Langen- 
beck's  is  the  most  common,  the  curved  incisions,  of  which 
Oilier 's  method  is  the  best  representative,  possess  great  advan- 
tages in  giving  more  room  and  exposing  the  joint  more  thor- 
oughly, especially  about  the  head  of  the  radius.  Hardly  any- 
body will  be  inclined  to  employ  transverse  incisions,  whether 
straight  or  curved,  combined  or  not  with  one  or  two  longitudinal 
incisions.  The  principal  direction  of  the  incision  will  always 
have  to  be  longitudinal  -if  the  muscles  and  their  nerves  are  to 
be  preserved.  The  only  method  which  we  have  to  mention 
according  to  Faraboeuf 's  description,  since  it  resembles  our  own, 
is  that  of  Auguste  Nelaton,  who  combines  an  external  longitu- 
dinal incision  upon  the  head  of  the  humerus  with  one  running  at 
a  right  angle  backward  from  the  head  of  the  radius  to  the  ulna. 
But  even  Nelaton  employs  it  mainly  for  the  sufficient  exposure 
of  the  head  of  the  radius  and,  like  Oilier,  pays  no  attention  to  the 
preservation  of  the  anconseus  quartus.  Hueter  likewise  and, 
according  to  Faraboeuf,  Marangos  have  recommended  cutaneous 
incisions  related  to  ours,  but  they  differ  in  the  principal  object 
and  intention  of  the  incision. 

201.  Resection  of  the  Diaphysis  of  the  Humerus. — The  ex- 
cision of  the  humerus  offers  less  simple  conditions  than  that  of 
the  femur.  The  mode  of  removal  of  the  upper  and  lower  ends 
maybe  gathered  from  the  description  of  the  corresponding  joint 
resection.  Upon  the  diaphysis  the  relation  of  the  radial  nerve 
must  be  principally  borne  in  mind.  The  nerve  curves  from 
within  around  the  posterior  surface  of  the  humerus  toward  the 
outer  side. 

The  external  bicipital  sulcus  is  the  only  line  in  which  we  can 
cut  down  upon  the  diaphysis  over  its  entire  length,  from  the 


UPPER   EXTREMITY.  237 

lower  end  of  the  surgical  neck  (in  the  region  of  which  the  cir- 
cumflex artery  and  nerve  must  be  spared)  to  the  condyles 
below.  We  divide  the  fascia  of  the  deltoid  so  that  the  anterior 
margin  of  the  muscle  can  be  drawn  backward  with  the  arm  in 
the  abducted  position;  then  we  open  the  fascia  of  the  biceps 
and  penetrate  close  to  the  margin  of  the  muscle  and  under  it 
along  the  coraco-brachialis  and  the  outer  margin  of  the  brachi- 
alis  internus  down  to  the  bone.  The  radial  nerve  with  the  off- 
shoots of  the  deep  brachial  artery  (collateralis  radialis)  remains 
on  the  outer  side;  in  the  lower  third  the  musculo-cutaneous 
nerve,  which  descends  between  the  biceps  and  brachialis  internus 
to  the  lateral  anterior  side,  is  drawn  medially. 

202.  Resection  of  the  Articulation  of  the  Humerus. 

a.  From  in  front,  in  disease  of  the  head  of  the  humerus  (Figs. 
112  and  113).  The  head  of  the  humerus  projects  considerably 
beyond  the  socket  in  front,  for  in  a  horizontal  direction  the 
diameter  of  the  socket  is  but  half  that  of  the  head  covered  with 
cartilage.  The  head,  therefore,  is  more  readily  accessible  from 
this  side  in  the  same  proportion  as  the  socket  is  exposed  with 
greater  difficulty  from  in  front.  The  simplest  method  is  the  an- 
terior longitudinal  incision  practised  by  Baudens,  Malgaigne, 
Eobert,  and  Dubreuil ;  but  perfected  particularly  by  Langenbeck 
and  his  pupils.  The  improvement  of  the  operation  by  Hueter, 
Oilier,  and  Chauvel,  who  substituted  for  the  vertical  incision  an 
oblique  one  from  the  acromion  downward  through  the  deltoid 
so  as  to  spare  the  latter,  appears  to  be  the  most  rational  pro- 
cedure, since  this  muscle  is  of  the  greatest  importance  for  sub- 
sequent movements.  The  incision  begins  above  the  coracoid 
process  on  the  clavicle  and  passes  down  along  the  anterior  mar- 
gin of  the  deltoid.  The  margin  of  this  muscle,  to  which  the 
clavicular  portion  of  the  pectoralis  major  muscle  is  closely  ad- 
joining, is  mapped  out  by  the  cephalic  vein.  This  is  cut  above 
or  dissected  out  toward  the  pectoralis.  If  necessary  the  deltoid  is 
detached  for  some  distance  close  to  the  clavicle,  bv  a  transverse 


238 


OPERATIVE    SURGERY. 


incision.     The  acromial  branches  of  the  thoracico-acromialis  and 
transverse  scapular  arteries  are  to  be  ligated. 

The  anterior  margin  of  the  deltoid  is  drawn  outward.  This 
brings  into  view  the  muscles  springing  from  the  coracoid 
process :  pectoralis  minor,  short  head  of  the  biceps,  and  coraco- 
brachialis.     At  the  lateral  margin  of  the  latter  we  cut  down  on 


Fig.  112.— Anterior  Resection  of  the  Humerus. 


the  bone  and,  the  arm  being  slightly  rotated  inward,  open  the 
sheath  of  the  biceps  tendon  above  the  sulcus  of  the  biceps  which 
can  be  distinctly  felt.  The  opening  is  made  downward  and  up- 
ward through  the  upper  wall  of  the  capsule  until  the  tendon  is 
exposed  at  its  attachment  to  the  upper  margin  of  the  socket  and 
can  be  readily  drawn  inward.  This  exposure  of  the  biceps  ten- 
don has  for  its  object  not  only  its  preservation,  but  it  is  intended 
especially  to  render  the  head  of  the  humerus  accessible  in  a  line 


UPPER   EXTREMITY. 


539 


along  which  the  muscular  attachments  meet  from  in  front  and 
behind.  Then  follows  the  separation,  by  vertical  incisions  close 
to  tho  bone  and  parallel  to  the  bicipital  sulcus,  of  the  tendons 
attached  to  the  capsule,  namely,  that  of  the  subscapularis  from 
the  tuberculum  minus,  those  of  the  supraspinatus  and  infra- 


Pectoralis  major  muscle 

ectoralis  minor  muscle 

laviele 
Coracoid  process 

bhoi  t  head  of  the  biceps  and  coraco- 
Jomt  cavity  [brachialis 

Biceps  tendon 


(  Divided  margins  of  the 
I  capsule 


Cephalic  vein 

"Humerus 
Deltoid  muscle 


Fig.  113. — Anterior  Resection  of  the  Humerus. 


spinatus  and  teres  minor  from  the  tuberculum  majus.  At  the 
same  time  the  humerus  is  rotated  so  that  the  joint  surface  is  ex- 
posed more  and  more,  first  anteriorly,  then  posteriorly. 

Any  transverse  incision  through  the  capsule  between  the 
head  and  the  socket  is  to  be  absolutely  avoided.  If  the  humerus 
requires  exposure  farther  downward,  regard  must  be  had  for 
the  anterior  and  posterior  circumflex  arteries  at  the  surgical 
neck  and  for  the  axillarv  nerve ;  the  former  may  need  ligation. 


240  OPERATIVE   SURGERY. 

h.  From  hehiyid  (Figs.  114,  115,  and  116)  when  the  socket  is 
largely  affected  or  in  diffuse  disease  of  the  joint. 

As  shown  in  Fig.  114,  the  cutaneous  incision  passes  from  the 
acromio-clavicular  joint  over  the  highest  part  of  the  shoulder 
along  the  spine  of  the  scapula  to  near  its  middle,  thence  down- 
ward in  a  curve  toward  the  posterior  axillary  fold,  ending  two 
fingers'  breadth  above  the  latter.  The  upper  part  of  the  incision 
penetrates  into  the  acromio-clavicular  articulation  (the  covering 
ligaments  of  which  are  severed)  and  in  its  further  course  runs 
along  the  upper  margin  of  the  spine.  The  descending  portion 
of  the  incision  divides  the  thick  fascia  along  the  posterior  mar- 
gin of  the  deltoid  muscle,  which  is  thus  exposed  in  its  lower 
portion,  when  the  finger  draws  the  muscle  vigorously  forward. 
The  fibres  of  the  deltoid  which  are  attached  farther  backward 
along  the  spine  must  be  cut,  and  thus  a  small  posterior  triangle 
of  the  muscle  is  placed  out  of  function. 

The  attachment  of  the  trapezius  is  separated  above  at  the 
spine,  the  supraspinatus  muscle  is  detached  with  the  elevator, 
as  is  the  infraspinatus  below,  until  the  finger  can  seize  the 
lateral  margin  of  the  spine  at  the  point  where  it  rises  from  the 
scapula. 

The  supraspinatus  and  infraspinatus  muscles  being  drawn 
aside,  the  spine  is  cut  through  at  this  point  with  a  blow  of  the 
chisel.  During  this  step  care  should  be  taken  lest  injury  be  done 
to  the  suprascapular  nerve,  which  descends  under  the  muscles 
named  from  the  supraspinatous  into  the  infraspinatous  fossa ; 
the  nerve,  however,  is  protected  by  the  inferior  transverse  scapu- 
lar ligament.  Before  cutting  the  bone  it  is  desirable  to  make  two 
gimlet-holes  for  the  subsequent  suture  of  the  divided  surfaces. 
Or  else,  the  periosteum  can  be  divided  backward  and  forward, 
a  small  piece  of  bone  excised,  and  the  periosteum  sutured  over  it. 
After  the  bone  is  cut,  the  acromial  portion  can  be  completely 
turned  forward  or  luxated  in  the  acromio-clavicular  articulation, 
by  the  exercise  of  some  force  and  the  insertion  of  a  sharp  hook. 


UPPER  EXTREMITY. 


241 


Teres  minor  muscle 
Deltoid  muscle  ' 

Posterior  margin  of  ^ 
the  deltoid  ^      - 

muscle 


Infraspinatus  muscle 

rticular  surface  of  the  clavicle 
Crista  scapulee 


Divided  surfaces  ot  the 
deltoid  muscle 


Divided  surfaces  of  the  deltoid 
muscle 


j  Divided  surface  of  the 
-|        ciista  sLdpiila; 
.irticular  surface  of  acromion 
^Articular  surface  of  clavicle 
>^'V;1  Supraspinatus  m 

Infraspinatus  m.    /-S 
i\  Teres  minor  m. 


^Divided  surface  of  crista  scap.; 

Articular  surface  of  acromion 

•^  Biceps  tendon  [vide 

''Articular  surface  of  cla- 

/  Post,  surface  of  socket 

'  (  Capsule  witli  post,  ten- /v5^\.^- 
'     dinous  attachments  /^        \L^^    Jt 
Supraspinatus  m.    ^^  -^  .^ 


Teres  minor  muscle 


Infraspinatus  muscle 


Figs.  114,  115,  and  116.-Posterior  Resection  of  the  Articulation  of  the  Humerus.     (The  divided  sur- 
faces of  the  deltoid  muscle  appear  much  too  long  in  the  illustrations,  as  merely  a  small  posterior 
tnangle  is  cut  off.) 
16 


242  OPERATIVE   SUEGERY. 

During  this  step  the  deltoid  becomes  spontaneously  detached  from 
the  muscles  of  the  scapula,  with  whose  smooth  under  surface  it 
is  connected  only  by  some  loose  connective  tissue  (Fig.  115). 

After  the  acromio-deltoid  flap  is  turned  over,  the  upper, 
outer,  and  posterior  surfaces  of  the  head  of  the  humerus  are  freely 
accessible,  covered  by  the  tendons  of  the  outward  rotators,  supra- 
spinatus,  infraspinatus,  and  teres  minor.  The  posterior  surface 
of  these  muscles  is  likewise  exposed.  Much  now  depends  on 
the  fact  that  the  incision  on  the  head  of  the  humerus  be  placed 
correctly  so  as  to  avoid  unnecessary  injury.  At  the  point  where 
the  muscles  named  with  their  tendons  are  attached  to  the  tuber- 
culum  majus  and  the  spina  tuberculi  majoris,  i.e.,  at  the  an- 
terior margin  of  these  attachments  and  the  posterior  margin 
of  the  palpable  bicipital  fossa,  a  longitudinal  incision  is  made 
upon  the  bone,  passing  upward  along  the  upper  margin  of  the 
supraspinatus;  thus  the  capsule  is  divided  on  the  upper  surface 
of  the  joint  and  the  biceps  tendon  is  exposed  as  far  as  its  at- 
tachment to  the  upper  margin  of  the  socket.  Along  the  posterior 
margin  of  the  biceps  the  attachments  of  the  external  rotators 
to  the  tuberculum  majus  are  separated  and  drawn  backward. 
In  this  way  the  biceps  tendon  is  freed  below  from  its  bony  fossa 
so  that  it  can  be  drawn  forward  and  the  sheath  of  the  biceps  laid 
bare  for  inspection.  In  order  to  facilitate  this  step  the  elbow  is 
brought  forward  and  the  arm  rotated  outward.  Now  the  attach- 
ment of  the  subscapularis  to  the  tuberculum  and  the  spina 
tuberculi  minoris  becomes  visible  and  is  separated  from  the  bone 
forward  and  inward.  It  is  quite  easy  to  spare  the  circumflex 
nerve  and  vessels  which  emerge  from  below  the  teres  minor 
muscle;  in  fact,  their  injury  does  not  come  into  question  when 
the  operation  is  correctly  performed  (Fig.  116). 

As  soon  as  the  head  is  entirely  freed — still  more  so,  of  course, 
when  it  is  removed  by  resection — we  obtain  an  excellent  view 
into  the  socket,  one  that  is  far  better  than  is  possible  by  the 
anterior  mode  of  operation.     It  need  hardly  be  pointed  out  that 


UPPER   EXTREMITY.  243 

this  is  at  present  of  special  importance,  in  comparison  with  the 
former  f>ractice,  when  it  was  almost  thought  to  be  a  matter  of 
course  that  in  resection  of  the  humerus  decapitation  of  the  head 
alone  was  performed.  Unless  the  affected  tissues  are  removed 
from  every  part  of  the  joint  in  tubercular  disease,  operative 
treatment  has  been  deprived  of  most  of  its  value. 

Resection  of  the  shoulder  joint  from  the  above-described 
posterior  curved  incision  not  only  allows  absolutely  free  inspec- 
tion of  the  joint,  but  it  fulfils  the  indication  of  keeping  the  del- 
toid with  the  other  shoulder  muscles  in  function,  for  it  injures 
neither  the  muscle  nor  the  afferent  nerve.  But  it  possesses  a 
material  advantage  over  resection  from  in  front,  inasmuch  as 
it  makes  it  possible,  in  the  case  of  absent  or  limited  disease  of 
the  head,  to  restrict  ourselves  to  the  detachment  of  the  muscles 
passing  from  the  posterior  surface  of  the  scapula  to  the  capsule, 
while  leaving  the  latter  intact  at  the  anterior  circumference  of 
the  head,  together  with  the  covering  subscapular  muscle  and 
the  coraco-humeral  ligament.  This  is  the  best  way  of  guarding 
against  the  frequent  subluxation  of  the  head  of  the  humerus 
toward  the  coracoid  process.  The  method,  therefore,  deserves 
special  consideration  in  arthrectomies. 

203.  Resection  of  the  Clavicle,  of  the  Sterno-clavicular  and 
the  Acromio-clavicular  Articulations. — As  the  clavicle  lies 
under  the  skin  for  its  entire  length,  its  resection  is  a  simple 
matter  whenever  it  can  be  made  subf)eriosteal.  After  dividing 
the  skin,  platysma  (with  the  supra-clavicular  nerves),  and  the 
fascia,  the  periosteum  is  readily  pushed  back.  Sawing  through 
the  clavicle  in  the  middle  facilitates  the  separation  of  the  two 
halves.  At  the  upper  margin  the  attachments  of  the  clavic- 
ular portion  of  the  sterno-mastoid  muscle  and  the  trapezius, 
at  the  lower  margin  the  clavicular  portion  of  the  pectoralis 
major  and  the  deltoid,  are  to  be  separated;  at  the  posterior 
surface  the  subclavian  muscle,  and  medially  the  costo-clavicular 
ligament. 


244  OPERATIVE   SURGERY. 

For  the  resection  of  the  acromio-clavicular  articulation 
merely  the  stout  mass  of  ligaments  on  the  surface  of  the  joint 
is  to  be  divided  to  make  the  clavicle  movable. 

The  sterno- clavicular  articulation  per  se  likewise  presents  no 
difficulty  from  an  anterior  incision ;  for  the  meniscus  facilitates 
the  separation  of  the  ends  of  the  joint.  But  where  the  excision 
cannot  be  made  subcapsulo-periosteal,  we  must  bear  in  mind, 
during  the  separation  of  the  interclavicular  ligament,  the  trans- 
verse vein  in  the  sternal  notch ;  during  the  separation  of  the 
sterno -mastoid  muscle,  the  continuation  of  the  same  vein  behind 
this  muscle  to  the  external  jugular  vein;  during  further  divi- 
sion of  the  subclavian  muscle  and  the  costo- clavicular  ligament, 
the  pleura  and  the  subclavian  vein. 

204.  Resection  of  the  Scapula  (Fig.  117). — Total  resection 
was  first  performed  by  Langenbeck  (Gies)  in  1855.  In  disease 
and  especially  in  tumors  of  the  scapula,  which  are  not  rare,  it  is 
important  that  this  bone  be  excised  thoroughly  but  without  un- 
necessary incidental  injuries.  The  periosteum  should  be  pre- 
served wherever  feasible,  together  with  the  covering  muscles, 
in  view  of  possible  regeneration.  On  the  other  hand,  where 
preservation  of  the  periosteum  is  out  of  the  question,  as  in 
tumors,  it  appears  to  be  particularly  desirable  to  remove  thor- 
oughly all  the  muscles  which  are  placed  out  of  function,  in 
order  to  prevent  relapses.  In  total  excision  of  the  scapula, 
these  include  the  muscles  moving  the  scapula  alone  or  acting 
from  the  latter  upon  the  arm. 

Curved  incision  from  the  point  at  which  the  acromion  must 
be  severed,  over  the  spine  of  the  scapula  to  its  posterior  margin, 
and  downward  to  the  angle  of  the  scapula.  It  is  a  great  advan- 
tage for  the  function  of  the  arm  if  a  good  part  of  the  acromial 
portion  can  be  preserved,  because  to  it  are  attached  important 
muscles — the  trapezius  from  above  and  the  deltoid  from  below. 
If  the  acromion  is  to  be  removed  completely,  the  incision  at  its 
beginning  at  once  passes  into  the  acromio-clavicular  articulation 


UPPER   EXTREMITY 


245 


and  divides  it  fully.     If  a  portion  is  preserved,  the  acromion  is 
severed  with  a  chisel  at  the  respective  point. 

The  triangular  flap  formed  by  the  above-described  incision  is 
turned  forward  over  the  latero-posterior  fibres  of  the  deltoid 
and  backward  over  the  ascending  portion  of  the  trapezius  to 
the  margin  of  the  latissimus  dorsi  muscle.     The  finger  is  in- 


FiG.  117. —Resection  of  the  Scapula. 

serted  under  the  exposed  posterior  margin  of  the  deltoid  and  the 
muscle  separated  as  close  as  the  disease  permits,  along  the  crista 
and  the  acromion  as  far  as  the  acromio-clavicular  articulation 
or  to  the  point  where  the  acromion  is  cut  with  the  chisel. 

In  this  way,  similarly  to  our  resection  operation  for  the 
shoulder  joint,  the  posterior  surface  of  the  capsule  with  the 
covering  tendons  of  the  outward  rotators  is  laid  bare.  If  the 
articular  portion  of  the  scapula  can  be  preserved,  one  muscle 


246  OPERATIVE   SURGERY. 

after  another  is  cut  upon  the  insinuated  finger  or  elevator,  and 
the  articular  portion  of  the  scapula  is  sawed  off.  But  if  the 
articular  portion  is  to  be  removed  likewise,  the  tendons  are  sep- 
arated from  the  head  of  the  humerus  as  in  resection  of  that 
bone ;  from  the  tuberculum  majus,  the  supraspinatus  and  infra- 
spinatus and  teres  minor ;  from  the  tuberculum  minus,  the  sub- 
scapular ;  and  below  from  the  spina  tuberculi  minus,  the  common 
attachment  of  the  latissimus  dorsi  and  teres  major. 

At  the  lower  margin  of  the  teres  minor  the  axillary  nerve 
and  posterior  circumflex  artery  are  to  be  preserved  or  the  latter 
ligated ;  farther  backward  the  circumflexa  scapulae  artery  must 
be  ligated. 

Next  the  trapezius  is  divided,  the  finger  being  insinuated 
under  its  fibres  from  the  cut  surface  of  the  acromion,  and  the 
muscle  is  separated  along  the  crista  scapulae,  also  behind  along 
the  inferior  edge  of  the  crista.  At  the  anterior  end  the  acromial 
branches  of  the  thoracico-acromialis  artery  must  be  ligated. 

The  scapula,  now  more  freely  movable,  is  drawn  down; 
the  muscles  attached  at  the  upper  margin  are  separated  antero- 
posteriorly;  the  omo-hyoid  combined  with  ligation  of  the  ter- 
minal branch  of  the  transversa  scapulae  artery,  the  levator 
scapulae  at  the  posterior  upper  angle  with  ligation  of  the  branches 
of  the  dorsalis  scapulae  artery  (transversa  colli). 

Then  the  broad,  rounded  attachment  of  the  serratus  anticus 
major  muscle  at  the  posterior  margin  of  the  scapula  is  separated 
when  the  scapula  is  turned  over,  and  finally  the  attachments  of 
the  thin  rhomboids  are  cut  at  the  same  point,  with  eventual 
ligation  of  the  dorsalis  scapulas  artery,  which  passes  along  the 
scapular  margin  on  the  serratus  posticus  superior  muscle. 


PART  IV. 

AMPUTATIONS   AND   EXARTICULATIONS. 

Introduction. 

The  complete  removal  of  a  limb  or  a  portion  of  it  is  called 
amputation.  If  the  removal  is  made  at  the  joint  it  is  generally 
called  exarticulation.  Quite  a  number  of  indications  for  the 
choice  of  the  method  of  amputation  have  become  nugatory  since 
the  introduction  of  the  antisejDtic  wound  treatment  and  the  im- 
provement in  the  technique  in  connection  with  the  latter.  In 
former  times  two  considerations  pre-eminently  determined  the 
surgeon  to  follow  a  definite  method  in  the  removal  of  a  portion 
of  a  limb : 

1.  The  desire  to  favor  rapid  and  undisturbed  recovery. 

2,  The  formation  of  the  most  useful  possible  and  painless 
stump. 

In  order  to  secure  rapid  healing,  the  wound  was  sought  to 
be  made  small,  smooth,  and  so  placed  that  the  margins  were 
well  nourished  and  coapted  themselves  spontaneously;  finally 
the  best  possible  escape  of  the  secretions  from  the  wound  surface 
was  aimed  at. 

Nowadays,  thanks  to  asepsis,  we  can  make  the  largest 
wound  heal  by  first  intention,  can  even  tolerate  considerable 
tension  of  the  wound  margins,  and  can  sufficiently  provide  for 
the  escape  of  the  wound  secretions,  which  at  any  rate  form  an 
element  for  a  few  days  only,  by  separate  small  openings. 

Moreover,  the  usefulness  of  the  stump  formerly  depended 
far  more  upon  the  method  than  it  does  to-day,  since  it  was  by 
the  method  that  the  surgeon  had  to  secure  the  mobility  of  the 


248  OPERATIVE    SURGERY. 

skin  on  the  stump,  the  correct  placing  of  the  tendons  and  mus- 
cles to  the  ends  of  the  bones,  and  the  removal  of  the  nerve 
stumps  from  the  region  of  the  cicatrix. 

At  present  even  these  considerations  are  largely  done  away 
with  when  the  course  of  the  wound  is  aseptic.  Amputation  is 
permissible  anywhere,  provided  sufficient  tegumentary  covering 
for  the  stump  can  be  obtained  and  the  cicatrix  (superficial  and 
deep)  can  be  protected  from  injurious  pressure  from  without. 

Development  of  the  Methods  of  Amputation. 

In  order  to  show  the  connection  of  the  various  methods  of 
amputation,  we  give  in  Figs.  118  to  122  a  synopsis  of  the  devel- 
opment of  the  complicated  incisions  from  the  simple  circular 
methods. 

The  simplest  and  oldest  methods  have  recently  again  become 
the  most  frequent.  These  are  the  circular  incisions.  By  circu- 
lar incisions  we  understand,  in  opposition  to  other  authors,  not 
only  transverse  incisions,  but  also  those  running  obliquely  to  the 
axis  of  the  limb,  provided  the  line  of  the  incision  continues  in 
one  direction,  or  the  incision  lies  in  a  single  plane.  In  the  fol- 
lowing diagrams  we  give  the  fundamental  type  of  the  circular 
method  from  which  all  other  methods  can  be  derived,  first  by 
the  addition  of  longitudinal  incisions,  and  then  by  the  rounding 
of  the  resulting  angles.  The  addition  of  a  single  longitudinal 
incision  with  rounding  of  the  angles  results  in  the  so-called  oval 
incision  (an  oval  with  a  pointed  side  is  strictly  not  an  oval). 
The  addition  of  two  longitudinal  incisions  with  rounding  of  the 
angles  results  in  true  flap  incisions.  The  incision  '•'■en  raquette'''' 
and  the  quadrangular  flaps  are  transitions  from  the  circular  to 
the  latter  methods.  Wherever  possible  the  circular  method  is 
to  be  preferred.  For  the  employment  of  the  oval  and  flap 
methods  we  shall  always  give  the  special  indications.  In  the 
introduction,  therefore,  we  can  confine  ourselves  to  the  descrip- 


AMPUTATIONS   AND    EXARTICULATIONS. 

Development  of  the  Methods  of  Ampi-tation. 

b.  Oblique  circular  incision  (oblique  method) 


249 


Fig.  118.— I.  Fundanieutal  Type  :  Circular  Metlioil. 

b.  Oblique  incision  rii  raqnette 


Fig  119  —II.  Transition  to  the  Oval  Method  (Incision  en  ragwef ^e=:Pedunculated  Circular  Jlethodj. 
a.  Transverse  oval  incision 


b.  Oblique  oval  incision 


Fig.  121.— IV.  Transition  to  the  Flap  Blethod  (Angular  Flap  3Iethod= Doubly  Pedunculated  Circular 

Method). 

b.  Unequal  flaps 


Fig.  1~'~'.— V.  Flap  Method  C^ounded  Flaps). 


250  OPERATIVE   SURGERY. 

tion  of  the  circular  methods  and  only  briefly  point  out  the  indi- 
cations. 

The  transverse  circular  method  secures  to  the  skin  the  best 
vascular  supply  and  nutrition.  It  is  contra-indicated  in  favor 
of  the  oblique  circular  method :  first,  when  more  healthy  skin 
is  present  on  one  side  of  the  limb  than  the  other,  otherwise  the 
amputation  would  have  to  be  carried  unnecessarily  high ;  sec- 
ondly, when  the  portion  of  the  limb  to  be  operated  on  is  much 
thicker  above  than  at  the  point  of  incision,  as  this  renders  the 
retraction  of  the  skin  difficult ;  thirdly,  when  the  cicatrix  cannot 
be  placed  at  the  end  of  the  stump  because  it  is  exposed  to  pressure 
from  below.  Figs.  129  and  130  sufficiently  illustrate  the  vary- 
ing position  of  the  suture :  in  the  transverse  circular  method, 
below  on  the  stump ;  in  the  oblique  circular  method,  above  the 
stump  laterally.  It  is  evident  without  much  argument  that  for 
the  reasons  above  given  the  transverse  circular  method  finds  a 
far  more  general  application  because  it  can  be  adapted  to  most 
cases,  is  easily  executed,  and  furnishes  a  movable  tegumentary 
covering  for  the  end  of  the  stump  which  is  free  from  cicatrices. 

The  incision  en  raquette  and  the  oval  method  give  more 
room  with  equal  preservation  of  integument,  or  equal  room 
with  greater  preservation  of  integument  (including  the  soft 
parts)  and  therefore  are  to ,  be  preferred  in  some  difficult  exar- 
ticulations  (at  the  thumb,  hip,  and  shoulder). 

The  flap  method  is  preferable  where  the  skin  or  the  other 
soft  parts  on  one  side  of  the  limb  call  for  special  consideration. 
This  is  the  case,  for  instance,  at  the  heel  and  the  muscles  at  the 
shoulder  and  hip.  The  drawback  of  the  flap  method,  which 
applies  in  a  minor  degree  even  to  its  fundamental  type,  the 
oblique  circular  method,  is  the  defective  nutrition  of  the  skin. 

The  performance  of  the  transverse  circular  method  is  suffi- 
ciently illustrated  in  Figs.  123,  124,  and  126. 

The  oblique  circular  method  (see  Figs.  126,  127,  and  128) 
differs  from  the  transverse  in  one  essential  point,  namely,  that 


AMPUTATIONS   AND   EXARTICULATIONS. 


251 


Fig.  12;^.— Transverse  Circular  Method:  showing  the       Fig.   I:i4.— Transverse   Circular   Method;  showing 
retraction  of  the  skin  and  the  application  of  the  how  the  deep  muscles  together  with  the  perios- 

knife.  teum  are  pushed  back  with  the  raspatory. 


Fig.  125. — Transverse  Circular  Method  after  Sawing       Fig.  120.— Oblique  Method;  pinching  up  of  the  skin 
the  Bone;  showing  the  hollow  cone  (in  sagittal  for  marking  the  lower  end. 

section)  from  the  skin  to  the  bone. 


Fig.  127.— Oblique  Method;  pinching  up  of  the  skin        Fig,  128.— Oblique  ^Method:  showing  tlie  ai^plication 
for  marking  the  upper  end.  of  the  knife  for  the  gradual  deep  division  of  the 

soft  parts. 


'   /  h.<       .1/5 


%^ 


Fig.  129.— Position  of  the  Suture  in  the  Transverse       Fig.   130.— Position  of  the  Suture  in  the  Obhque 
Circular  Method.  Method. 


252  OPERATIVE   SURGERY, 

the  skin  is  lifted  from  the  underlying  tissue  and  must  be  dis- 
sected back  with  the  knife,  while  in  the  transverse  circular 
method  it  is  merely  drawn  back. 

Another  difference  lies  in  this,  that  the  relation  of  the  cutane- 
ous incision  to  the  point  of  division  of  the  bone  must  be  deter- 
mined in  varying  ways.  The  plane  in  which  the  limb  is  ablated 
forms  a  wound  surface  for  the  covering  of  which  integument  must 
be  spared.  In  the  transverse  circular  method  the  knife  must  be 
applied  one-half  the  greater  diameter  of  the  limb  (measured  at 
the  point  of  division  of  the  bone)  below  the  line  along  which  the 
bone  is  sawed;  in  the  oblique  circular  method,  the  whole  diam- 
eter of  the  limb.  In  the  latter  case  the  upper  end  of  the  oblique 
incision  is  at  the  level  where  the  bone  is  divided  (Fig.  127). 
These  measurements  should  be  taken  very  liberally,  since  one  to 
two  centimetres  must  be  available  for  the  broad  coaptation  of  the 
wound  margins.  The  elastic  retraction  of  the  wound  margins 
need  not  be  considered  for  wounds  to  be  healed  by  first  inten- 
tion, as  it  is  readily  overcome  by  the  suture  and  becomes  useful 
for  a  good  adaptation  of  the  integument  to  the  wound  surface. 
In  the  open  wound  treatment  the  measurements  should  be 
doubled. 

The  cutaneous  incision  severs  the  skin,  subcutaneous  adipose 
tissue,  and  superficial  fascia.  Both  hands  of  an  assistant  re- 
tract the  skin  vigorously  during  the  transverse  circular  incision, 
the  knife  cutting  the  tightening  fibres  always  close  to  the  edge 
of  the  skin. 

In  the  oblique  circular  method  the  upper  and  lower  ends  are 
best  marked  by  small  incisions  made  by  pinching  up  a  fold  of 
skin  as  in  Figs.  126  and  12Y.  The  two  small  angles  of  this 
"rhomboid  incision"  also  facilitate  the  subsequent  suture.  The 
left  hand  then  grasps  the  longer  skin  margin  and  draws  it  up 
with  great  force  so  as  to  detach  it  from  its  base  to  the  level  of 
the  upper  end  of  the  incision  (Fig.  128).  Wherever  possible 
the  fascia  is  included.     The  edge  of  the  knife  must  never  be 


AMPUTATIONS   AND   EXARTICULATIONS.  253 

directed  toward  the  llap,  but  always  against  the  underlying 
tissue. 

At  the  margin  of  the  retracted  skin  the  muscles  are  divided 
in  a  plane  transverse  to  the  axis  of  the  limb  (Fig.  128) ;  where 
the  muscle  is  thick,  the  superficial  layers  are  first  severed  and 
allowed  to  retract  upward,  and  the  deeper  layers  are  divided  in 
a  higher  plane  because  the  superficial  muscles  usually  retract 
more  strongly. 

The  same  plan  is  followed  in  the  puncture  method.  This  is 
admissible  in  the  formation  of  two  short  equal  flaps ;  the  divided 
skin  being  drawn  back,  the  muscles  detached  from  the  bone,  the 
knife  inserted  in  one  of  the  angles  between  the  flaps,  carried 
along  the  bone,  and  pushed  through  in  the  other  angle  between 
the  flaps,  so  as  to  divide  the  muscles  obliquely  along  the  margin 
of  the  skin  by  one  smooth  cut.  The  same  is  done  on  the  other 
side,  the  muscles  being  lifted  off.  This  operation  requires  a 
long,  sharp,  two-edged  knife. 

Then  follows  the  incision  through  the  periosteum  in  the 
plane  in  which  the  muscles  have  retracted  (Fig.  124).  This  is 
pushed  without  cutting  along  the  bone  as  far  as  necessary  for 
covering  the  sawed  surface  of  the  bone  completely  with  perios- 
teum, and  the  bone  is  severed  at  the  margin  of  the  detached 
periosteum.  Where  the  periosteum  adheres  closely,  as  on  the 
rough  lines  of  epiphyses  and  tendinous  attachments,  it  is  sepa- 
rated with  the  knife. 

Where  no  muscles  are  to  be  divided,  as  on  certain  joints,  all 
the  soft  parts  at  the  margin  of  the  retracted  skin  are  severed 
down  through  the  periosteum,  and  the  bone  is  enucleated  sub- 
periosteally,  in  the  case  of  joints  subcajDsularly,  to  the  point  of 
division  (Oilier 's  subcajjsulo-periosteal  method). 

In  all  cases  in  which  the  end  of  the  bone  is  to  act  as  a  direct 
support,  as  especially  on  the  epiphyses,  it  must  be  rounded  off, 
either  by  curved  sawing  or  by  osteoplastic  covering  with  a 
rounded  bony  process,  as  in  Pirogoff's  and  Gritti's  operation. 


254  OPERATIVE    SURGERY. 

After  the  removal  of  the  limb  the  vessels  are  ligated,  best 
with  tine  silk ;  the  stumps  of  nerves  and  tendons  are  searched 
for,  drawn  out,  and  cut  off  at  the  level  of  the  wound  surface. 
Where  the  suture  fails  to  bring  the  raw  surfaces  in  exact  coap- 
tation throughout,  a  glass  drainage  tube  with  large  lateral  open- 
ings is  inserted  through  a  special  small  incision  (for  its  direction 
see  the  figure  showing  the  cleavage  lines  of  the  skin). 

Then  follow  a  few  deep  button  sutures  and  an  uninterrupted 
exact  cutaneous  suture. 

X.  Lower  Extremity. 

Amputations  at  the  Foot. 

For  the  foot  the  chief  rule  is  to  make  the  incisions  for 
amputation  so  that  no  cicatrix  extends  to  the  sole.  Therefore 
oblique  incisions  and  their  modifications  are  here  the  normal 
methods.  The  longer  flap  must  always  lie  on  the  plantar  side. 
The  second  rule  is  to  look  upon  the  foot  always  as  a  whole, 
excepting  isolated  amputations  of  the  toes,  i.e.,  to  ablate  it  in 
a  transverse  line  (Major). 

205.  Removal  of  the  Toes,  with  or  without  Metatarsal 
Bones  (Fig.  131). — Amputations  and  exarticulations  of  the  toes 
are  fully  analogous  to  those  of  the  fingers.  For  the  phalanges 
and  interphalangeal  joints  the  oblique  method  is  indicated;  for 
the  metatarsals  and  the  metatarso-phalangeal  joints,  the  oval 
method.  The  dorsal  portion  of  the  incisions  extends  to  the 
bone  and  enucleates  it  subperiosteally. 

On  the  first  and  last  toe  the  dorsal  portion  of  the  incision  is 
made,  not  on  the  middle  of  the  phalanges  and  the  metatarsus, 
but  more  toward  the  median  line  of  the  foot  so  as  to  bring  the 
cicatrices  out  of  reach  of  lateral  pressure. 

206.  Exarticulation  of  all  the  Toes  (phalango-metatarsal  ex- 
articulation ;  Fig.  132). — All  the  toes  are  circumscribed  by  an 
incision  at  the  base  where  they  separate  from  the  common  in- 


LOWER  EXTREMITY. 


255 


tegument  of  tlio  foot,  so  that  tlie  incisions  coincide  with  tlie 
interdigital  folds.  On  the  sole  the  incision  runs  exactly  in  the 
groove  of  the  ball  of  the  toes.  Laterally  on  tlie  great  and  little 
toes  two  dorso-lateral  longitudinal  incisions  are  added. 

The  toes  being  flexed'  strongly  toward  the  sole,  the  dorsal 
tendons  are  severed  as  high  as  possible  at  the  margin  of  the 


Tig.  131.— Exaiticulation  of  the 
Great  Toe,  Exarticulation  of 
the  Second  Toe  with  the  Ble- 
tatansal,  Amputation  of  the 
Third  Toe,  Amputation  of  the 
Fifth  Metatarsal. 


Fig.  133. — Exarticulation  of  the 
Toes. 


Fig.  133.— Metatarsal  Ampu- 
tation. 


wound,  a  small  knife  cuts  the  lateral  ligaments  and  the  dorsal 
and  plantar  joint  capsule,  and  lastly  the  plantar  tendons  as  high 
as  possible. 

207.  Metatarsal  Amputation  (Pig.  133). — This  operation 
has  the  advantage  over  the  metatarso-tarsal  exarticulation 
that  the  attachments  of  the  chief  muscles  of  the  foot  are  all 
preserved,  not  only  tibialis  posticus  and  peroneus,  but  also 
tibialis  anticus,  peroneus  brevis  and  tertius.     The  foot,  there- 


256 


OPERATIVE   SURGERY. 


fore,  remains  movable  in  all  directions.  It  is  likewise  quite 
useful  for  support,  as  the  important  support  of  the  fifth  meta- 
tarsal at  its  posterior  end  is  preserved,  the  only  one  lost  being 
that  of  the  head  of  the  first  metatarsal. 

Oblique  incision  v^ith  the  formation  of  a  plantar  flap,  which 
is  at  once  separated  in  such  a  way  as  to  pass  with  long  strokes 
of  the  knife  through  the  muscles  obliquely  to  the  point  where 


Tuber.of  fifth 
metatarsal 


)   Tubercle  of 
Istmetatars'l 


Tubercle  of  the 
first  metatarsal 


Fig.  134  (Plantar  surface;.  '  Fig.  135  (Dorsal  surface). 

Figs.  134  and  135.— Tar  so- metatarsal  Exarticulation  (Lisfranc). 

the  bones  are  severed,  in  order  to  spare  the  branches  of  the  inter- 
nal and  external  plantar  artery.  All  the  plantar  bones,  one  after 
the  other,  are  circumscribed  with  a  small  scalpel  and  sawed  off. 
208.  Metatarso-tarsal  Exarticulation  (Lisfranc;  Figs,  lo-i 
and  135). — Passing  between  the  metatarsus  in  front,  the  cunei- 
form bones  and  the  cuboid  behind.  The  jDlantar  flap  extends  to 
the  middle  of  the  balls  of  the  toes.  The  joint  is  characterized 
laterally  by  the  tuberosity  of  the  fifth  metatarsal,  behind  which 
lies  the  line  of  the  joint  (Fig.  135).     On  the  medial  side  a  small 


LOWER   EXTREMITY.  257 

eminence,  the  base  of  the  first  metatarsal,  is  distinctly  palpa])le. 
Oblique  incision  with  two  dorso-lateral  cuts  so  as  to  lay  bare  the 
line  of  the  joint. 

The  line  of  the  joint  is  convex  downward  and  outward,  has 
a  depression  above,  due  to  the  recession  of  the  second  cuneiform 
bone  which  stands  back  from  the  oblique  convex  line  2  to  3  cm. 
from  the  third  cuneiform,  and  1  cm.  from  the  first.  The  two 
joints  are  opened  first  (the  first,  third,  fourth,  and  fifth),  the 
second  last.  The  strongest  ligament  is  between  the  first  cunei- 
form and  the  base  of  the  second  metatarsal  (compare  Fig.  135), 
and  until  that  is  severed  the  joint  cannot  be  made  to  gape. 

As  in  all  operations  on  the  foot,  the  vessels  are  preserved  in 
the  plantar  flap. 

Where  the  tegumentary  covering  is  insufficient,  the  removal 
of  the  first  cuneiform  does  not  lessen  the  function  of  the  foot 
any  more  than  Lisfranc's  exarticulation  alone. 

209.  Anterior  Intertar sal  Exarticulation  {J agQY]  Fig.  137). 
— Between  the  cuneiform  bones  in  front  and  the  scaphoid  be- 
hind, the  cuboid  being  sawn  through.  Operation  like  Lis- 
franc's,  somewhat  less  integument  being  preserved.  The  method 
has  the  advantage  over  Chopart's  of  preserving  the  strong  liga- 
ment from  the  calcaneus  to  the  cuboid  and  scaphoid  bones. 

210.  Posterior  Intertarsal  Exarticulation  (Chopart;  Fig. 
136). — Between  calcaneus  and  astragalus  behind,  the  cuboid  and 
scaphoid  in  front.  The  operation  has  often  resulted  in  a  bad 
stump,  owing  to  equinus  position  of  the  foot  and  chafing  at  the 
anterior  lower  circumference  of  the  calcaneus.  The  best  pre- 
ventive measures  for  this  are,  to  attach  the  dorsal  flexor  tendons 
firmly  to  the  stump,  prophylactic  tenotomy  of  the  Achilles 
tendon,  and  care  for  healing  by  first  intention. 

The  line  of  the  joint  is  characterized  on  the  medial  side  by 
the  marked  projection  of  the  tuberosity  of  the  scaphoid  bone 
behind  which  it  lies,  and  laterally  by  an  eminence  on  the  body 
of  the  calcaneus  in  front  of  which  it  lies.     The  oblique  incision 

17 


258 


OPERATIVE   SURGERY. 


strikes  the  line  of  the  joint  above,  and  below  passes  to  the  pos- 
terior end  of  the  balls  of  the  toes.  Two  small  dorso-lateral  in- 
cisions facilitate  the  exarticulation. 

We  penetrate  into  the  joint  between  the  head  of  the  astraga- 
lus and  the  scaphoid  which  is  convex  below ;  on  the  outer  side  and 
more  deeply  the  knife  should  again  be  directed  toward  the  toes. 


Tubercle  of  the 
calcaneus 


Jhopart's  line 


\  Tuber,  of  the 
I  scaphoid  bone 


Fig.  13G  (Dorsal  surface).    '  Fig,  137. 

Fig.  136. — Medio-tarsal  Exarticulation  (Chopart). 
Fig.  137.— Medio-tarsal  Amputation  (Jager).     Horizontal  section  of  the  Foot  after  Heitzmann. 

for  the  lateral  portion  of  the  joint  between  calcaneus  and  cuboid 
is  concave  forward.  If  the  edge  is  directed  backward  we  reach 
the  joint  between  astragalus  and  calcaneus. 

The  main  connection  between  the  bones  is  the  Y-shaped 
ligament  from  the  body  of  the  calcaneus  to  the  scaphoid  and 
cuboid  bones. 

211.  The  terni  "tarsal  amputation"  can  be  applied  to  the 
operation  in  which,  after  exarticulation,  the  joint  surfaces  of  the 
astragalus  and  calcaneus  are  sawed  off  because  the  tegumentary 


LOWER   EXTREMITY. 


259 


covering  does  not  suffice  for  a  Chopart  operation.  As  the  cap- 
sule of  the  ankle  joint  is  not  opened  (the  operation  extends  to 
within  1  cm.  of  the  margin  of  the  cartilage  of  the  astragalus 
joint)  the  resulting  foot  is  still  movable. 

212  a.   Siibastragaloid  Exarticulation  (Malgaigne,  Textor; 
Figs.  139  and  143). — Oval  incision,  beginning  horizontally  under 


<=S27( 


Post,  intertarsal  exarticulation  CChopart) 
Anterior  intertarsal  exarticulation  (Jager) 

Tarso-metatarsal  exarticulation  (Lisfranc) 
Metatarsal  amputation 
Fig.  138. 


Fig.  139.— Subastragaloid  Exarticulation  (Malgaigne,  Textor). 

the  tip  of  the  external  malleolus,  extending  toward  the  dorsum  to 
Chopart's  line  (which  is  distinctly  marked,  as  above,  by  the 
tuberosity  of  the  scaphoid),  along  which  it  descends  vertically 
to  the  sole  on  the  medial  side,  back  to  its  point  of  beginning  on 
the  outer  side. 

Chopart 's  joint  is  opened  from  above  between  the  head  of 
the  astragalus  and  the  scaphoid.  Then,  without  penetrating 
deeper  into  this  joint,  the  narrow  knife  is  turned  immediately  up- 
ward and  backward  under  the  head  of  the  astragalus  so  as  to 


260 


OPERATIVE   SURGERY, 


sever  the  strong  ligamentum  interosseum  astragalo-calcaneum 
in  the  sinus  tarsi,  and  the  calcaneus  is  enucleated,  first  on  the 
upper,  outer,  and  lower  surface,  then  inward,  and  lastly  behind. 


Fig.  140.— Exarticuiation  of  the  Foot  (Syme,  Uiodifled). 


On  the  medial  side  the  most  difficult  point  is  the  sustentaculum 

tali,  which  extends  high  up. 

When  the  tegumentary  covering  is  insufficient  the  head  of 

the  astragalus  is  sawed  off. 

2126.   Osteoplastic  Suhastragaloid  Amputation. — Performed 

by  Hancock  by  the  attachment  of  the  severed  tuber  calcanei  to 
the  sawed  lower  surface  of  the  astragalus. 
The  indication  for  the  operation  is  of  ex- 
ceptional joccurrence. 

213.  Exarticuiation  of  the  Foot  (Syme ; 
Figs.  140  and  141). — The  total  removal  of 
the  foot  at  the  ankle  joint  has  been  per- 
formed by  Syme,  a  flap  having  been  formed 
from  the  integument  of  the  heel.  This 
method  has  the  drawback  that  in  place  of 
the  enucleated  tuber  calcanei  a  cavity  is 

Fig.   141.  — Frontal   Section  . 

through    the    Ankle    Joint,    left  whlch    IS    UOt  filled  Up. 

Worthy  of  recommendation  is  the  oval 
incision  with  the  formation  of  a  flap  from  the  medial  side,  be- 
ginning transversely  over  the  tip  of  the  external  malleolus  (Fig. 


LOWER  EXTREMITY. 


261 


140).  After  dividing  the  skin,  the  strong  lateral  ligaments  (lig. 
fibulo-calcaneiim  and  astragalo-fibularia)  and  the  peroneal  ten- 
dons are  severed  and  the  extensor  tendons  at  the  margin   of 


Fig.  142.— Osteoplastic  Exarticulation  of  the  Foot  (Pirogoff). 

the  retracted  skin ;  the  ankle  joint  capsule  is  opened  and  enu- 
cleated close  to  the  bone  along  the  calcaneus,  downward  from 
the  flaps.  The  malleoli  are  circumscribed  with  the  knife  and 
sawed  off. 

214.   Osteoplastic  Amputation  of  the  i^oof  (Pirogoff ;  Figs. 
142  and  143). — The  leg  bones  are  sawed  off  immediately  above 


Subastragaloid  exarticula- 
tion (Malgaigne) 


Fig.  143.— Osteoplastic  Exarticulation  of  the  Foot  (PirogoflP). 

the  cartilaginous  surface  and  to  the  sawed  surface  is  attached 
that  of  the  tuber  calcanei  to  lengthen  the  leg.     The  preservation 


262  OPERATIVE   SURGERY. 

of  the  tuber  calcanei  has  the  great  advantage  that  the  skin  of 
the  heel  remains  well  nourished  and  the  so-called  heel  cap  re- 
mains filled.     It  is  far  preferable  to  Syme's  exarticulation. 

The  simj)lest  and  most  reliable  method  is  the  following: 
Tenotomy  of  the  Achilles  tendon.  Incision  beginning  at  the 
level  of  one  malleolus,  extending  in  the  axis  of  the  leg — the 
foot  being  kept  at  a  right  angle — over  the  heel  ("stirrup"  inci- 
sion), and  ending  at  the  level  of  the  opposite  malleolus.  The 
incision  throughout  is  carried  vigorously  down  to  the  bone  and 
severs  the  tendons  within  and  without  completely. 

Second  incision  extending  directly  forward  at  a  true  right 
angle  from  the  ends  of  the  first  incision,  so  that  the  anterior 
end  lies  a  good  thumb's  breadth  in  front  of  the  ankle  joint. 
This  incision  severs  only  the  skin  and  fascia,  at  the  margin  of 
which  the  extensor  tendons  are  divided. 

The  astragalo- crural  joint  is  opened  from  in  front,  the  lateral 
ligaments  are  divided  under  the  malleoli  until  the  astragalus  is 
laid  bare  to  its  posterior  end.  Then  the  tuber  calcanei  is  sawed 
off  vertically  behind  the  astragalus,  in  the  plane  of  the  stirrup  in- 
cision, and  turned  up  with  the  skin  of  the  heel.  The  malleoli  and 
articular  portions  of  the  leg  bones  are  circumscribed  with  the 
knife  and  sawed  off  transversely.  The  suture  exactly  coapts 
the  sawed  surfaces.     The  gait  subsequently  is  excellent. 

In  order  to  avoid  the  turning  of  the  calcaneus,  which  in  our 
opinion,  however,  is  quite  serviceable,  many  surgeons  have 
sawed  the  calcaneus  obliquely  (Schede,Volkmann)  or  horizontally 
(Dupasquier,  Lefort)  or  at  a  curve  and  angle  (Bruns,  Bockel). 

For  the  horizontal  division  the  oval  incision  is  to  be  recom- 
mended (similar  to  Fig.  139),  beginning  horizontally  under  the 
tip  of  the  external  malleolus.  By  this  horizontal  incision  room 
is  gained  for  sawing. 

All  these  modifications  have  the  drawback,  as  compared 
with  the  above-described  method,  that  a  portion  of  the  cicatrix 
is  placed  too  near  the  inferior  surface  of  the  foot. 


LOWER  EXTREMITY. 


203 


215.  Amputation  of  the  Ley  (Figs.  144,  145,  and  140). — We 
indicate  the  suitable  incisions  merely  by  illustrations;  for  the 
performance  we  refer  to  the  descrijjtion  of  amputations  in  gen- 
eral. The  oblique  incision  is  the  method 
most  frequently  employed ;  at  the  upper 
and  lower  end  it  is  best  to  form  the  flap 
in  front  so  as  to  cover  the  epif)hyses,  which 
are  sawed  in  a  curve. 

About  the  diaphysis,  however,  the  ob- 
lique incision  is  made  so  that  the  flap  lies 
antero-externally,  lest  the  anterior  edge  of 
the  tibia  (which  should  always  be  rounded 
off)  be  pressed  too  firmly  against  it.  It  is 
well  to  separate  the  periosteum  of  the 
inner  surface  of  the  tibia  with  the  tegu- 
mentary  flap  so  as  to  protect  the  bone. 

The     interosseous     ligament    adheres 


Fig.  144.— Intra-malleolar  Amputation. 


Fig.    145.  —  High,  Medial,  and  Intra- 
malleolar  Amputation  of  the  Leg. 


firmly  to  the  bone  and  is  dissected  up  with  the  periosteum  by 
means  of  the  knife.  The  division  of  the  muscles  between  the 
bones  must  be  made  smoothly  in  a  transverse  plane  so  that 
the  vessels  are  divided  with  one  cut. 

Throughout  the  length  of  the  leg  the  vessels  to  be  ligated 
are:  tibialis  antica  artery   (and  vein)  on  the  interosseous  liga- 


264 


OPERATIVE   SURGERY. 


ment,  tibialis  postica  artery  on  the  deeper  calf  muscles,  in  the 
lower  two- thirds  the  peroneal  artery  on  the  dorsal  surface  of  the 
fibula  or  of  the  flexor  hallucis  longus  muscle. 


Extensor  digit,  longus  muscle 

Tibialis  anticus  nerve 

Tibialis  antica  artery 

Peroneus  longus  muscle 

Tibialis  posticus  muscle 

Peroneal  artery 

Soleus  muscle 

Gastrocnemius  muscle. 


Tibialis  anticus  muscle 


Flexor  dig.  communis  m. 
Tibialis  postica  artery 

Tibialis  posticus  nerve 


^Soleus  muscle 
•  Fig.  146.— Transverse  Section  ot  the  Leg,  after  a  Photograph. 

216.  Exarticulation  of  the  Knee  (Figs.  147  and  150). — Fur- 
nishes an  excellent  stump  when  the  course  is  aseptic.  Whether 
the  preservation  of  the  articular  cavity  (Socin)  is  a  permanent 
advantage  is  still  uncertain. 


Fig.  147.— Exarticulation  of  the  Knee. 


Oblique  incision  with  anterior  flap,  beginning  posteriorly  in 
the  line  of  the  joint  and  ending  in  front  four  fingers'  breadth 
below  the  spine  of  the  tibia.  If  the  leg  is  kept  half  flexed  (at 
an  angle  of  135°  with  the  thigh),  the  direction  of  the  incision 
lies  in  the  prolongation  of  the  axis  of  the  thigh    (Fig.  147). 


LOWER   EXTREMITY. 


265 


The  skin  with  the  fascia  is  dissected  back,  the  capsule  with  the 
ligamentum  patellae  is  divided  in  front,  the  meniscuses  and 
lateral  ligaments  in  front  and  laterally,  then  along  the  inter- 
condyloid  eminence  of  the  tibia  the  crucial  ligaments  are  sepa- 
rated, the  posterior  wall  of  the  capsule  is  severed  along  the  tibia, 
and  the  operation  is  completed  by  a  transverse  incision  through 
the  posterior  soft  parts. 

Where  the  removal  of  the  patella  appears  necessary  on  ac- 
count of  pro  thesis,  the  flap  is  turned  over,  the  patella  circum- 
scribed with  the  knife,  and  enucleated  subperiosteally. 


Fig.  148.— Intracondylic  Amputation  (Garden). 

The  main  vessels  are  the  popliteal  artery  and  vein.  Among 
the  larger  branches  the  articularis  genu  artery  and  occasionally 
muscular  branches  to  the  gastrocnemius  require  ligation. 

217.  Amputation  of  the  Femur  (Figs.  14S-152). — Formerly 
and  even  now  one  of  the  more  frequent  amputations.  An 
oblique  incision  is  to  be  recommended  for  any  level,  and  so  is 
the  circular  method,  with  the  exception  of  the  lower  end,  owing 
to  the  bad  position  of  the  cicatrix. 

218.  Intracondylic  Amputcdion  (Fig.  1-18;  Garden  and  Bu- 
chanan).— In  amputation  at  the  lower  end  of  the  femur  in  chil- 
dren Buchanan  simply  divides  the  condyles  in  the  epiphyseal 
line. 

Garden  saws  off  the  condyles  in  a  curve  at  their  greatest 


266 


OPERATIVE   SURGERY. 


circumference  and  by  this  means  obtains  an  excellent  stump 
which  easily  bears  the  weight  of  the  body.  Oblique  incision 
beginning  at  the  level  of  the  condyles  and  extending  in  front 
to  the  spine  of  the  tibia. 

219.  Supracondy lie  Amputation  {Fig.  151)  is  performed  by 
an  oblique  incision  with  flap  (Langenbeck)  on  the  anterior  inner 
side  because  the  adductors  draw  the  thigh  forward  and  inward; 
were  the  incision  made  directly  anterior,  the  bone  would  be 
crowded  too  far  toward  the  inner  angle  of  the  wound. 


Fig.  149.— Osteoplastic  Supracondylic  Amputation  (Gritti) 


A  modification  of  this  frequent  amputation  is  Gritti's  supra- 
condylic amputation  (Fig.  149).'  Oblique  incision,  the  upper 
end  lying  posteriorly  directly  over  the  eminence  of  the  condyles, 
the  lower  end  in  front,  two  fingers'  breadth  under  the  patella. 
The  ligamentum  patellae  is  divided  at  the  upper  end.  After 
sawing  through  the  femur  and  the  cartilaginous  surface  of  the 
patella,  the  latter  is  attached  to  the  femur  or  nailed  to  it. 

220.  The  amputation  through  the  middle  (Fig.  151),  owing 
to  the  massive  muscles,  is  best  performed  in  such  a  way  as  to 
form  two  short  vertical  flaps  (Lisfranc  and  Esmarch),  and  after 
their  retraction  to  divide  the  muscles  transversely  by  a  smooth 
cut.     Very  smooth  wounds  can  also  be  obtained  by  inserting 


LOWER   EXTREMITY.  2G7 

the  knife  on  both  sides  of  the  bone  after  the  division  of  the  skin. 
When  the  muscles  are  well  developed,  the  periosteum  should 
be  pushed  up  several  centimetres  in  order  to  obtain  sufficient 
integument  and  to  be  able  to  cover  the  sawed  surface  with 
periosteum. 

221.  The  high  amputation  (Fig.  151)  is  performed  by  an  oval 
incision  in  a  manner  resembling  exarticulation  of  the  femur. 
The  longitudinal  portion  of  the  incision  is  on  the  outer  side, 
extends  down  to  the  bone,  and  permits  its  enucleation  sub- 
periosteally  to  the  point  of  division. 


Outer  surface 
Biceps  muscle 

Popliteal  artery- 
Popliteal  vein- 
Tibialis  posticus  nerve- 
Peroneal  nervt' 
Fig.  150.— Transverse  Section  through  the  Lower  End  of  the  Femur  and  Knee  Joint  (after  Braune). 


1 —  Inner  surface 


Sartorius  muscle 
Great  saphena  vein 


During  amputation  of  the  femur  in  the  lower  tjiird  (Fig. 
152)  the  vessels  to  be  ligated  are  the  femoral  artery  and  vein, 
the  articularis  genu  suprema  artery  antero- internally,  and  pos- 
sibly the  superior  arteries  of  the  knee  joint.  In  the  upper  two- 
thirds,  besides  the  femoral  artery  and  vein,  the  profunda  femoris 
artery  and  in  the  upper  third  large  branches  of  the  external 
circumflex  artery  require  ligation. 

222.  Exarticulation  of  the  Hip  (Figs.  153  and  154:) . — Though 
formerly  a  capital  operation,  the  removal  of  the  thigh  at  the 
hip  joint  can  now,  thanks  to  the  improved  technique,  be  per- 
formed without  hesitation  even  on  relatively  feeble  patients. 

Eose  (Liining)  extirpates  the  thigh  like  a  tumor,  either 
ligating  the  vessels  immediately  after  their  division  or  doubly 
ligating  them  before  they  are  severed.  In  the  case  of  tumors 
reaching  high  up  into  the  region  of  the  hip  joint  this  procedure 


268 


OPERATIVE   SURGERY. 


Crural  muscle        pectus  femoris  muscle 
Vastus  extemus  musclp         i        f    vastus  internus  muscle 

,  Saphenus  nerve 

Sartorius  muscle 
Femoral  artery 

Inner  surface 

GracDis  muscle 

Adductor  magnus  m. 

Semi-membranosus'muscle 
Fig.  152.— Transverse  Section  through  the  Thigh  (after  a  Pho- 
tograph). 


( Incision  for 
/     resection 


\  Incision  for  am- 
(        putation 


Fig.  151.— High,  Median,  and  Supra- 
condylic  Amputation  of  the  Femiu". 


Fig.  153.— Exarticulation  of  the  Hip. 


LOWER  EXTREMITY. 


269 


»^W' 


is  the  most  suitable.  For  these  rea- 
sons the  technique  requires  no  special 
description,  as  it  varies  in  each  case. 

Wherever  the  soft  parts  about  the 
hip  joint  can  be  preserved  this  should 
unquestionably  be  done.     For  in  the 
subsequent  use  of  an  artifical  limb  the     I 
function  of  the  muScles  in  the  stump     ) 
after  exarticulation    of   the   hip  is  of  ^ 
the   greatest  value.     Especially  after 
operating   subperiosteally  a   stump  is 
obtained  which  gives  vigorous  mobility 
in  all  directions,  similar  to  the  high 
amputation  of  the  femur. 

The  elastic  bandage  is  applied  in 
the  inguinal  fold  for  the  prophylactic 
arrest  of  hemorrhage,  a  figure-of-eight 
turn  being  invariably  made  around  the 
pelvis  to  prevent  dov/nward  displace- 
ment. At  the  height  calculated  in  the 
usual  manner  (see  General  remarks  on 
amputations)  the  circular  incision  is 
carried  through  the  skin  and  at  its 
mai'gin  the  corresponding  incision 
through  the  muscles  to  the  bone,  which 
is  sawed  through  after  the  separation 
of  the  periosteum.  Careful  ligation 
of  the  vessels  follows,  after  which  the 
elastic  bandage  is  removed. 

More  suitable  than  the  simple  cir- 
cular   method    is    an    oval  incision,   the    Fig.  154.— Frontal  section  of  the  Hip 
.  i     •  1  ^^'^  Knee  Joints,  after  Henle. 

prolongation     being    on    the    outside 

(Fig.  151)   of  the  bone,  or  eventually  a  short  anterior  and  pos- 
terior flap. 


i.'"VS 


i^l*i^-x'>.. 


^^!^a 


l:^ 


m 


270  OPERATIVE   SURGExiY. 

The  exarticulation  of  the  upper  end  of  the  femur  is  per- 
formed in  various  ways. 

After  the  amputation  Beck  divides  on  the  outer  surface  of 
the  femur  the  soft  parts  and  enucleates  the  bone,  separating 
with  the  knife  the  attachments  of  the  periosteum  at  the  Hnea 
aspera,  of  the  tendons  (of  the  three  gluteal  muscles,  the  pyri- 
formis,  external  and  internal  obturator  with  gemelli,  quadratus 
femoris  at  and  under  the  great  trochanter,  ilio-psoas  at  the 
lesser  trochanter),  and  of  the  capsule  about  the  anterior  and 
posterior  inter-trochanteric  line.  The  ligamentum  teres  is  torn 
by  rotating  the  bone  several  times. 

We  (Kocher,  Eoux)  precede  the  amputation  by  a  resection 
of  the  hip,  with  a  shortened  posterior  incision  about  the  great 
trochanter  (which  see),  ligating  all  the  bleeding  vessels,  and 
then  only  apply  the  elastic  ligature  and  make  the  amputation. 
Our  method  has  the  advantage  that  the  inevitable  hemorrhage 
from  the  smaller  vessels  (obturator,  circumflex,  and  sciatic 
arteries)  occurs  at  the  beginning  instead  of  the  end  of  the 
operation. 

Otherwise  the  same  vessels  are  to  be  ligated  as  in  the  high 
amputation  of  the  femur. 

Y.  Upper  Extremity. 

223.  Amputation  and  Exarticulation  of  the  Fingers  (Figs. 
155,  156,  and  15Y). — For  the  fingers  the  main  rule  is  to  preserve 
even  the  smallest  stump,  provided  it  can  remain  connected  with 
the  tendons  and  be  covered  with  healthy  integument.  All 
methods,  therefore,  are  good.  Where  the  choice  is  open,  flaps 
from  the  volar  side  are  to  be  preferred,  so  as  to  avoid  cicatrices 
in  the  palm.  The  corresponding  oblique  incision  is  the  most 
suitable,  in  fact  necessary  for  the  ungual  phalanx.  The  posi- 
tion of  the  joints  is  readily  located  by  bending  the  fingers,  since 
the  line  of  the  joint  is  always  peripheral  from  the  dorsal  emi- 


UPl'ER   EXTREMITY. 


271 


nences  (Fig.  155).  Here  the  knife  is  applied  and  carried 
obliquely  downward  toward  the  palm.  The  phalanx  being 
strongly  flexed,  the  attachment  of  the  extensors  to  the  base  is 
divided,  then  the  dorsal  capsule,  the  two  lateral  ligaments,  and 
the  flexor  tendons. 

During  amputations  the  volar  flap  must  be  turned  back,  so 
as  to  circumscribe  the  bone  with  the  knife. 

For   the   exarticulation    of   the   fingers    in    the    i)halango- 


Interoi-sei  and 
lumbricals 


Extensor  digitoi-um  longus 


Fig.  155.— Position  of  the  Joints  of  the  Fingers  In    Fig.  156.— Exarticulation  of  Fingers:  Fifth, 
Flexion,  and  Attachments  of  the  Tendons.  Second,  Fourth  with  Metacarpal.  First 

with  Metacarpal  (Dorsal  Surface). 

Tnetacarpal  and  in  the  metacarpo-carpal  joint  the  oval  incision 
is  used,  whose  longitudinal  portion  extends  backward  over  the 
head  of  the  metacarpus  or  over  the  base  of  this  bone.  The 
tendons  are  divided  at  the  margin  of  the  retracted  skin, 
then  the  periosteum  is  opened  and  detached,  at  the  articular 
ends  simultaneously  with  the  capsular  attachment. 

In  the  case  of  the  thumb,  index,  and  little  finger,  the  dorsal 
portion  of  the  incision  is  placed  toward  the  median  line  of  the 
liand  instead  of  toward  the  middle  of  the  bone  or  joint. 


272 


OPERATIVE   SURGERY. 


In  removing  the  metacarpals  of  the  thumb  and  little  finger 
it  is  a  matter  of  special  importance  to  keep  the  short  thenar  and 
hypothenar  muscles  quite  intact,  as  in  this  way  very  useful 
movable  stumps  are  obtained,  especially  with  subperiosteal  enu- 
cleation of  the  bone. 

For  the  exarticulation  of  the  whole  finger,  with  or  without 
the  metacarpal,  the  point  for  the  transverse  incision  is  exactly 
defined  by  the  transverse  fold  between  the  palm  and  finger ;  no 
incisions  must  be  made  farther  back  in  the  palm. 

224.  Exarticulation  of  the  Hand  (Fig.  15Y). — For  this  as 
well  as  for  the  amputation  of  the  forearm  the  most  variable 


styloid  process  of  the  radius 


Fig.  157.— Exarticuiatioii  of  the  Third  Finger,  Exarticulation  of  the  Hand,  Amputation  of  the 

Forearm. 


methods  are  admissible  by  which  a  longer  stump  can  be  obtained. 
Contrary  to  Major's  rule  with  reference  to  the  foot,  no  ampu- 
tation should  be  made  in  the  transverse  line  so  long  as  a  movable 
finger  or  portion  of  the  hand  can  be  preserved. 

Oblique  incision,  the  upper  end  in  the  line  of  the  wrist  joint, 
the  lower  end  in  the  palm.  Under  strong  volar  flexion  the  ex- 
tensor tendons  and  the  dorsal  capsule  are  divided;  also  the 
lateral  ligaments  and  tendons  under  the  styloid  processes  pro- 
jecting farther  downward  (external  ulnar,  extensors  and  ab- 
ductor of  the  thumb),  and  the  upper  row  of  carpal  bones  which 
is  convex  above  is  enucleated.  In  the  line  of  the  joint  the 
bundle  of  flexor  tendons  is  divided  and   anteriorly   the   volar 


UPPER  EXTREMITY.  273 

flap  freed  in  its  entire  thickness.  The  volar  flap  has  the  advan- 
tages of  excellent  nutrition,  delicate  tactile  sensation,  and  occa- 
sionally the  preservation  of  movable  muscular  stumps. 

The  vessels  requiring  ligation  are  the  ulnar  artery  or  its  two 
branches  passing  to  the  volar  arch  in  the  palm  and  the  branch 
of  the  radial  artery  to  the  superficial  arch ;  on  the  dorsal  side 
the  trunk  of  the  radial  artery  passing  to  the  deep  arch. 

225.  Amputation  of  the  Forearm  (Figs.  157  and  158). — This 
presents  no  peculiarities  deviating  from  the  general  rules.  An 
oblique  incision  with  volar  flap  is  to  be  recommended  for  the 

Pronator  teres  muscle 
Radialis  interaus  muscle\^^        ^ — /^>C  Radial  nerve 
Palmaris  longus  muscle^,,^^  /^^^^^^^^^\^  Supinator  longus  muscle 
Flexor  digitorum  sublimis  I  /^R^^^^S^^l^eSO?^^-^'^^'''^^^  radial  muscles 

Internal  ulnar  muscle-^  fl^^^^^^/t^^^^^^wl     c     ■     ^     ■.       ■ 

^T-7^S^^^^j  W.-iP"^^^  I — Supinator  brevis  muscle 
Ulnar  nerve  — X^^^^^^'^S^^^^CS^^/' — -Extensor  digit,  communis  m. 

Ulnar  artery  "'A^ ^External  ulnar  nerve 

Flexor  digit,  profundus  ^^■iC^^^^^^^^^^C.A.nconsdus  quartus  muscle 

Fig.  158.— Transverse  Section  of  the  Forearm  in  the  Upper  Third,  after  a  Photograph. 

same  reasons  as  at  the  wrist  joint.  It  prevents  cicatrices  on 
the  volar  side. 

Ligation  of  the  radial  and  ulnar  arteries  and  the  interosseal 
lying  under  and  medially  from  the  latter. 

226.  Exarticiilation  of  the  Elhotv  (Figs.  159  and  160).— It 
is  an  error  repeated  incessantly  by  instructors  in  operating,  that 
the  joint-line  of  the  elbow  is  to  be  determined  from  the  tip  of 
the  olecranon.  It  should  be  determined  from  the  condyle  of 
the  radius,  which  can  always  be  felt  on  the  dorso-radial  side. 

Oblique  incision  from  the  line  thus  determined  in  the  bend 
of  the  elbow,  extending  a  hand's  breadth  under  the  tip  of  the 
olecranon  on  the  dorsal  side.  When  the  forearm  is  flexed  at 
an  angle  of  135°  the  direction  of  the  incision  is  parallel  to  the 
prolonged  axis  of  the  arm.  The  dorsal  flap  with  the  peri- 
osteum, and  the  attachment  of  the  triceps  and  anconseus 
18 


274 


OPEEATIVE   SURGERY. 


qiiartus  are  freed  beyond  the  tip  of  the  olecranon  and  the  dorsal 
surface  of  the  humerus.     In  front  the  soft  parts  with  the  joint 


Fig.  159.— Exarticulation  of  the  Elbow;  Longituauial  Incision  after  Braune. 

capsule  are  divided  transversely,  the  flap  being  lifted  and  the 
knife  carried  into  the  humero- radial   articulation.     With  the 


External  lateral  ligamen 


Condyle  of  the  radius  for  de-  i 
termlning  the  line  of  the  joint  I 


Annular  ligamen 


iDternal  lateral  ligament 


division  of  the  tense  internal  ligament  the  operation  is  finished. 
Ligation  of  the  brachial  artery  in  the  bend  of  the  elbow. 


UPPER   EXTREMITY. 


275 


227.  Amputation  of  the  Arm  (Fig.  161). — In  order  to  obtain 
a  broad  covering  of  the  arm  stump  we  must  bear  in  mind 
that  the  arm  is  much  flattened  from  without  inward  when  the 
volar  surface  is  directed  forward.  Flaps  should  be  formed  from 
the  broad  side.     Accordingly  in  an  oblique  incision  the  upper 


Fig.  Itil.— Amputation  of  the  Humerus. 


end  of  it  falls  in  the  internal  bicipital  sulcus.     The  biceps  mus- 
cle retracts  strongly. 

The  upper  limit  for  securing  a  useful  stump  by  amputation 
is  determined  by  the  surgical  neck  to  which  the  joint  capsule  is 
continued  on  the  medial  side ;  on  the  other  side,  by  the  attach- 
ments of  the  deltoid,  pectoralis  major,  and  latissimus,  which 
must  maintain  the  equilibrium  as  the  chief  abductors  and  ad- 
ductors. Eegarding  the  rules  for  the  high  amputation  compare 
the  exarticulation  of  the  humerus.  Ligation  is  required  for 
the    brachial    and    the    deep   brachial   arteries,  together   with 


276 


OPERATIVE   SURGERY. 


smaller  branches  (collateral  ulnar  arteries).  When  the  bone  is 
sawed  through  at  the  turning-point  of  the  radial  nerve,  its 
resection  is  particularly  necessary. 

228.  Exarticulation  of  the  Humerus  (Fig.  162). — In  remov- 
ing the  arm  at  the  shoulder  joint  it  is  as  necessary  as  in  exar- 
ticulation of  the  hip  that  wherever  possible  a  musculo-periosteal 


V     (!_ 


Fig.  163.— Exarticulation  of  the  Humerus. 

stump  be  preserved.     This  will  be  important  in  the  use  of  an 
artificial  limb. 

The  incision  is  made  in  accordance  with  this  requirement. 
It  is  admissible,  in  a  manner  analogous  to  that  of  the  hip,  to 
make  a  high  amputation  at  the  level  of  the  axillary  folds,  by 
means  of  a  circular  incision ;  and,  after  sawing  the  bone,  to  add 
a  longitudinal  incision  on  the  anterior  surface  as  in  resection  of 
the  humerus,  and  to  enucleate  the  upper  end  of  the  humerus. 


UPPER   EXTREMITY.  277 

However,  this  is  not  absolutely  necessary,  as  the  hemorrhage 
can  be  controlled  as  certainly  through  a  simple  oval  incision. 
'  The  longitudinal  incision  begins  under  the  clavicle  on  the 
outer  side  of  the  coracoid  process  and  passes  downward  at  the 
anterior  margin  of  the  deltoid  to  the  level  of  the  axillary  fold, 
then  turns  laterally  around  the  belly  of  the  deltoid,  extends 
transversely  across  the  dorsal  surface  and  upward  under  the 
anterior  axillary  fold,  and  terminates  in  the  first  part  of  the 
incision. 

Immediately  after  tracing  the  first  longitudinal  incision  the 
cephalic  vein  and  branches  of  the  thoracico-acromial  artery  are 
ligated.  In  front  we  penetrate  into  the  depth  to  the  bone  at 
the  margin  of  the  deltoid  (the  uppermost  anterior  fibres  are 
severed),  between  it  and  the  pectoralis  major,  divide  the  capsule 
in  the  bicipital  sulcus  and  upward  to  the  socket,  and  separate 
it  with  the  tendinous  attachments  of  the  subscapularis,  also  the 
periosteum  with  the  attachment  of  the  pectoralis  major  on  the 
inner  side,  the  attachments  of  the  supraspinatus,  infraspinatus, 
and  teres  minor  on  the  outer  side  of  the  bone,  so  that  the  head  of 
the  humerus  can  be  readily  forced  out  forward  and  upward.  In 
cutting  upon  the  surgical  neck,  the  ligation  of  the  circumflex 
arteries,  or  at  least  of  the  anterior  artery,  may  come  in  ques- 
tion. When  the  cutaneous  incision  is  then  completed,  it  will 
be  easy  to  ligate  the  main  vessels  before  dividing  the  deep  soft 
<  parts  transversely,  and  to  separate  the  latissimus  dorsi  and  teres 
minor  muscles  from  the  spine  of  the  lesser  tuberosity.  Dur- 
ing this  step  we  must  carefully  avoid  injury  of  the  axillary 
nerve,  which  turns  behind  the  bone  over  the  teres  major  in  order 
to  supply  the  deltoid.  For  the  latter  is  the  chief  muscle  of  the 
remaining  stump. 

229.  Exarticulation  of  the  Ann  ivitli  the  Slioidder  Girdle 
(Fig.  163). — As  a  rule  the  oj)eration  is  performed  for  tumors 
which  have  involved  the  shoulder  joint  with  the  scapula,  fre- 
quently also  the  axillary  glands,   vessels,  and  muscles.     The 


278 


OPERATIVE   SURGERY. 


preservation  of  any  stump,  therefore,  is  out  of  the  question. 
Of  course,  cases  occur  in  which  only  a  portion  of  the  scapula 
(acromion  and  articular  portion)  need  be  removed  with  the  arm. 
Prophylactic  arrest  of  hemorrhage  is  out  of  the  question. 
The  first  care,  therefore,  in  making  the  incisions  is  the  ligation 


Fig.  163.— Exarticulation  of  the  Shoulder  Girdle. 


of  the  large  vessels.  Otherwise  the  direction  of  the  incision  is 
to  be  largely  modified  according  to  the  involvement  of  the  skin. 
The  rule  is  an  oval  incision,  the  longer  portion  of  which 
passes  over  the  clavicle,  beginning  in  the  supraclavicular  fossa. 
The  periosteum  of  the  clavicle  is  divided,  the  clavicle  sawn 
through  and  bent  apart  with  sharp  hooks,  and  the  subclavian 
muscle  is  carefully  separated.  The  fascia  is  opened  and  the 
subclavian  artery  and  vein  and  the  brachial  plexus  are  laid 


UPPER   EXTREMITY.  279 

bare.  The  nerves  are  divided  singly,  the  vessels  doubly  ligated 
and  cut. 

If  the  hemorrhage  is  to  be  reduced  to  the  minimum,  other 
vessels  must  be  ligated,  as  follows:  Branches  of  the  subclavian 
which  emerge  laterally  over  the  scaleni,  namely,  the  three 
branches  of  the  thyro-cervical  trunk  which  pass  from  the 
scalenus  upward  (ascending  cervical  artery),  upward  and  out- 
ward (superficial  cervical  artery),  and  laterally  behind  the  clav- 
icle (transverse  scapular  artery) ;  finally  the  thick  transversa 
colli  artery  which  passes  backward  over  or  through  the  brachial 
plexus  so  as  to  supply  the  scapular  muscles  (levator,  supra- 
spinatus)  and  then  descends  along  the  scapula  (as  the  dorsalis 
scapulae)  between  the  rhomboid  muscles  and  the  serratus  posti- 
cus superior.  By  this  means  we  guard  against  serious  hemor- 
rhage. 

Then  the  anterior  incision  is  carried  into  the  depth  between 
the  clavicular  portion  of  the  pectoralis  major  and  the  deltoid  on 
the  medial  side  of  the  large  vessels,  dividing  first  the  pectoralis 
minor  at  the  coracoid  process,  then  the  attachments  of  the 
pectoralis  major  and  latissimus  dorsi  as  close  as  possible  to  the 
humerus,  during  which  step  the  skin  is  severed  antero- posteriorly 
through  the  axilla.  Then  the  arm  together  with  the  scapula 
and  clavicle  can  be  lifted  off. 

The  posterior  incision  passes  backward  over  the  acromion 
and  downward  on  the  dorsal  surface  to  the  jDosterior  axillary 
fold.  Along  the  upper  margin  of  the  clavicle,  acromion,  and 
spine  of  the  scapula  the  upper  portion  of  the  trapezius  is 
divided ;  along  the  lower  margin  of  the  spine,  the  lower  jDortion 
of  this  muscle. 

The  scapula  is  now  attached  only  by  its  upper  margin  to  the 
omo-hyoid  and  levator  scapulae,  by  its  posterior  margin  to  the 
serratus  anticus  major  and  rhomboids. 

Berger  has  done  very  meritorious  work  in  developing  the 
method  of  the  exarticulation  of  the  shoulder  girdle. 


